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Exploratory description of financing and sustainability in American Indian and Alaska Native system of care communities : summary report & appendices.

National Evaluation of the Comprehensive Community Mental
Health Services for Children and Their Families Program
Exploratory Description
of Financing and
Sustainability in American
Indian and Alaska Native
System of Care
Communities
Summary Report & Appendices
July 2009
Submitted to:
Substance Abuse and Mental Health Services Administration
Child, Adolescent and Family Branch
1 Choke Cherry Road, Room 6-1047
Rockville, MD 20857
Under Contract Number 280–05–0135
Submitted by:
Walter R. McDonald & Associates, Inc.
ICF Macro
Study Team:
Holly Echo-Hawk, M.S. Michelle DiMeo, M.A.
Nancy Weller, B.A. Carolyn Lichtenstein, Ph.D.
Katherine Lewis Brown, M.B.A. Elizabeth Oppenheim, J.D.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report & Appendices • Page i
Table of Contents
Introduction ................................................................................................................................. 1
Description of the Study ................................................................................................................. 2
Tribal Starting Place—The Cultural Framework ................................................................................ 3
Planning for Sustainability .............................................................................................................. 4
Political Entities and Sustainability ................................................................................................... 5
Developing Sustainable Services ..................................................................................................... 6
Strengthening Infrastructure ........................................................................................................... 8
Role of Data in Financial Sustainability ............................................................................................ 9
Assessing and Mobilizing Funding Sources .................................................................................... 10
Determining the Cost of Services .................................................................................................. 12
Medicaid as a Funding Source ..................................................................................................... 12
Developing and Sustaining Key State Partnerships .......................................................................... 14
Implications for Long-Term Financial Sustainability ........................................................................ 15
Recommendations for Financing and Sustainability in American Indian and Alaska Native
System of Care Communities ....................................................................................................... 16
Planning for Sustainability ....................................................................................................... 16
Interacting With Political Entities Regarding Financing ............................................................... 16
Developing Sustainable Services .............................................................................................. 17
Strengthening Infrastructure .................................................................................................... 17
Using Data in Financial Sustainability Planning ........................................................................ 18
Assessing and Mobilizing Funding Sources ............................................................................... 19
Determining the Cost of Services ............................................................................................. 19
Determining the Feasibility of Medicaid as a Funding Source .................................................... 20
Developing and Sustaining Key State Partnerships .................................................................... 20
Appendices
Appendix A. Understanding the Challenge: The Cultural Framework ...................................... A1
Appendix B. Purpose and Description of the Exploratory Description Study ............................... B1
Appendix C. Findings From Discussions With Project Directors, Fiscal Managers and Tribal
Board or Council Representatives ...................................................................... C1
Appendix D. Findings From Interviews With State Representatives ........................................... D1
Appendix E. National Evaluation Sustainability Study Findings for Tribal System of Care
Communities .................................................................................................... E1
Appendix F. Discussion Guides ............................................................................................. F1
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report & Appendices • Page ii
Index of Tables
Table 1. American Indian and Alaska Native System of Care Grant Communities ........................... 2
Table B–1. American Indian and Alaska Native System of Care Grant Communities ......................... B2
Table E–1. General Strategies for Maintaining Tribal Communities’ Systems of Care ........................ E2
Table E–2. Financing Strategies for Maintaining Tribal Communities’ Systems of Care ...................... E3
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 1
Introduction
he Comprehensive Community Mental
Health Services for Children and Their
Families Program (also referred to as the
Child Mental Health Initiative [CMHI]),
funded by the Center for Mental Health Services
(CMHS) at the Substance Abuse and Mental Health
Services Administration (SAMHSA), was initiated
in 1992 to provide grants to States, communities,
territories, and American Indian and Alaska Native
(AI/AN) communities to develop systems of care to
serve children and adolescents with, or at risk for,
emotional disorders and their families.1,2 A system
of care promotes the full potential of all children
and youth by addressing their physical, emotional,
intellectual, cultural, and social needs.3
AI/AN communities entered the system of care
movement in 1994 with the initial Federal grant
award to the Restoration of K’e: The Navajo Nation
Child Mental Health Project, located on the Navajo
Reservation in New Mexico. The experiences of
this initial Tribal venture into the world of national
system of care reform helped to open the doors for
the Tribal communities that followed. Fifteen Tribal
communities were funded between 1994 and 2006
and they represent the broad diversity of Tribal
people (see Table 1 for a list of the grant
communities and their primary States of
residence).4 Their cultures and languages are as
diverse as their geographic locations, which include
rural reservations, Urban Indian communities, and
Alaska Native villages.
Half of the Tribal system of care communities were
previous recipients of a 3-year Circles of Care
planning grant. The Circles of Care Initiative—
1 For the purpose of this report, the terms “American
Indian/Alaska Native,” “Native American,” “Indian,” and
“Tribal” are one and the same.
2 The 125 communities that have received, or were receiving
at the time of the study, funding through CMHI represent all
50 States and two U.S. territories.
3 http://systemsofcare.samhsa.gov/, retrieved March 25, 2008.
4 CMHI grants were awarded to 13 Tribal sovereign nations
and two Urban Indian organizations between 1994 and 2006.
described by community representatives as
invaluable—supports federally recognized Tribes,
State-recognized Tribes, and Urban Indian
communities with financial and technical assistance
to plan a culturally respectful mental health system
of care.
The material presented in this report is supported by
additional material included in the following report
appendices:
■ Appendix A. Understanding the Challenge: The
Cultural Framework
■ Appendix B. Purpose and Description of the
Exploratory Description Study
■ Appendix C. Findings from Discussions with
Project Directors, Fiscal Managers, and Tribal
Board or Council Representatives
■ Appendix D. Findings from Interviews with
State Representatives
■ Appendix E. National Evaluation Sustainability
Study Findings for Tribal Communities
In addition, the discussion guides used to gather the
data summarized in this report can be found in
Appendix F.
T
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 2
Description of the Study
The purpose of the exploratory study, conducted
between July 2007 and January 2008, was to
examine the unique financing opportunities and
challenges of Tribal systems of care in relation to
program sustainability. The overall goal of
collecting the information from this exploration was
to use study results to identify and improve
financing and sustainability strategies specifically
for Tribal communities. It is important to note that
the findings of the study are based on a small
number of participants (two or three staff from each
of the 15 Tribal system of care communities) and
the findings cannot be generalized to all Tribal
communities.
The National Evaluation Team facilitated telephone
discussions and conducted site visits with Tribal
system of care communities funded by CMHS
between 1994 and 2006. Telephone discussions
with the project director and fiscal manager of all
15 communities covered broad thematic areas that
included perspectives on sustainability; the
economic, social, and political environment;
infrastructure; services; and funding. The
discussions, conducted from July through October
2007, were unstructured, but were steered by a
topical guide.
In addition, site visits were conducted with five
Tribal system of care communities between
November 2007 and January 2008. On-site
discussions were held with a project director, fiscal
manager, Tribal Board or Council representative,
and State representative. These discussions explored
financing and sustainability successes and
challenges in more depth than the telephone
discussions. Discussions with State representatives
Table 1. American Indian and Alaska Native System of Care Grant Communities
System of Care Population of Focus State Funding Period
Graduated Communities
Restoration of K’e: The Navajo Nation
Child Mental Health Project Navajo Nation New Mexico 1994–1999
Sacred Child Project North Dakota Tribes North Dakota 1997–2003
Kmihqitahasultipon (“We Remember”)
Project Passamaquoddy Nation Maine 1997–2003
With Eagles’ Wings Project Northern Arapaho and Shoshone Tribes Wyoming 1998–2004
M’no Bmaadzid Endaad Program Sault Ste. Marie Tribe of Chippewa Indians
and Bay Mills Tribe of Chippewa Indians Michigan 1998–2004
People Working Together Project Yup’ik Eskimo and Athabascan Indians Alaska 1999–2005
Nagi Kicopi–Calling the Spirit Back
Project Oglala Sioux Tribe South Dakota 1999–2005
Ak-O-Nes Project Northern California Tribes California 2000–2006
Currently Funded Communities (at the time of the study)
Choctaw Nation CARES Project Choctaw Nation Oklahoma 2002–2008
“Ch’eghutsen” A System of Care Alaska Native Communities Alaska 2002–2008
Urban Trails Project Urban Indian Community California 2003–2009
The Po’Ka Project (Blackfeet Children
System of Care) Blackfeet Nation Montana 2005–2011
Tiwahe Wakan (Families as Sacred) Yankton Sioux Tribe South Dakota 2005–2011
Seven Generations System of Care Urban Indian Community California 2005–2011
Sewa Uusim Systems of Care Pascua Yaqui Tribe Arizona 2006–2012
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 3
focused on State agency support for Tribal systems
of care.
A Native researcher conducted all discussions in a
culturally competent manner; respect for AI/AN
historical concerns about data gathering and data
analysis guided the entire research process. The
notes taken for all discussions were qualitatively
analyzed by isolating emergent themes.
Tribal Starting Place—The
Cultural Framework
The core values of a system of care specify that
services should be child-centered, family-focused,
community-based, and culturally competent—all
values shared with many Tribal communities as part
of their traditional values and beliefs. Most of the
Tribal communities further capitalize on this
alignment by translating the system of care
terminology and approach into phrases and terms
that are meaningful to their Tribal cultures. Tribal
communities understand the relationship between a
cultural foundation to services and improved
outcomes for Tribal youth and families, and use the
system of care framework to strengthen the
development of healthy Tribal nations.
The cultural importance of program sustainability
cannot be ignored. Sustainability of community
mental health programs is especially important
within Tribal communities that lack financial
resources. For example, one leader of a Tribal
community-based substance abuse prevention and
intervention program stated,
We have a responsibility to our program
recipients. They’ve had so many losses in their
lives, and [if we] come in for a year or two or
three and give them hope, only to have the
program go away, we’ve just caused another
loss and further hopelessness in their lives.5
5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing
substance abuse in American Indian and Alaska Native
communities: The Healthy Nations Initiative. In Nebelkopf, E.
Although the
system of care
principles and
Tribal belief
systems may be
in alignment,
Tribal systems of
care continue to
face serious
challenges in
developing and
implementing
financing
strategies for
sustainability. Financing any system of care is a
strategic endeavor that involves determining what
funds will be used, how they will be used, and how
they will be managed.6 However, the financing of
Tribal systems of care is particularly complicated.
This is due to many reasons, including the lack of
financial resources in remote Tribal communities,
the impact of Tribal–State history on the
willingness and ability to pursue financial
partnerships, and the potential funding sources’ lack
of knowledge about the advantages of working with
Tribes.
Adding to the complexity of the challenge is the
meaning of federally recognized Tribes’ sovereign
status as it relates to financing; the role of Tribal
self determination; the history of confusing policies
guiding support for Tribal services; the financial
options of Tribes that are recognized by States, but
lack Federal recognition; and the unique financial
situation faced by Urban Indian communities. These
challenges become barriers to reform when there is
& Phillips, M., (Ed.), Healing and mental health for Native
Americans. New York: Altamira Press.
6 Stroul, B. A. (2007). Issue brief 1: Effective strategies to
finance a broad array of services and supports (RTC study 3:
Financing structures and strategies to support effective
systems of care, FMHI pub. #235-IB1). Tampa, FL:
University of South Florida, Louis de la Parte Florida Mental
Health Institute, Research and Training Center for Children’s
Mental Health.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 4
a lack of cross-cultural and cross-system problem
solving.
Planning for Sustainability
Findings
Many of the Tribal system of care community
representatives stressed that active and early
planning for sustainability was critical. Community
representatives discussed how planning for
systemwide transformation built on a foundation of
Tribal beliefs and Tribal ownership provided an
opportunity to break away from a previous cycle of
non-productive “planning” that had been
reactionary and short-term in nature. Some
community representatives felt that recognizing the
impact of colonialism and historical trauma on the
Tribal community’s efforts to plan was an essential
first step in breaking non-productive cycles. One
community representative argued that there was
little value in building large-scale services with
Federal funding if there was no effort to plan for
long-term sustainability. Additionally, a few
communities cautioned that fast program growth
resulting from an infusion of Federal funds can
diminish the quality of service provision if the
service structure is not carefully planned;
community representatives recommended
expanding services carefully and only to the extent
that supports are in place to ensure quality service
provision.
The Tribal system of care communities engaged in a
number of approaches to planning, which usually
began with their seeking input from the local
community on needs and service priorities as part of
their logic model development.7
Many Tribal
community representatives discussed the value of
gathering data about their community’s strengths
and needs to help with program planning and to
7 A logic model is a process to articulate the theory of change
underlying systems of care for children and families. It is a
tool for describing theories and beliefs about how and why
service systems are expected to produce particular results.
increase their competitive edge with other funding
opportunities.
Some of the planning approaches used by the Tribal
communities included
■ developing local definitions of health and
wellness with the input of community members
and Tribal elders;
■ having Tribal elders help design strategies to
infuse Tribal values, practices, and cultural
supports throughout their system of care;
■ analyzing all of the fund sources that affected
the Tribal youth and families in their States of
residence, and then determining which of the
fund sources they currently accessed and which
they needed to pursue;
■ determining the true cost of services using time
and cost studies;
■ incorporating visits to the State Medicaid office
to better understand the Medicaid provider and
billing requirements;
■ using a backward mapping process to identify
the community’s ultimate goal and detail the
steps necessary to reach the goal without
sacrificing cultural integrity;
■ developing ways to build evidence of
effectiveness and a cost base for traditional
practices;
■ developing methods to track the non-Federal
matching fund requirement.
Discussion
The close alignment of system of care values and
principles with many Tribal values and beliefs
empowers a Tribal system of care to include the
Tribal community in its planning efforts. System of
care grant requirements such as providing culturally
competent services that best meet the community to
be served, creating ways to ensure family-driven
and youth-guided care, consistently evaluating the
factors related to child and family progress, and
developing a social marketing plan that helps the
community understand the meaning of a system of
care are all opportunities for a more culturally and
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 5
linguistically appropriate and inclusive planning
model. Authentic community involvement in all
levels of planning not only gives family voice to the
process, but can clarify community needs and
wants, and helps to determine which elements of the
system of care should be sustained after the Federal
grant ends.
The Tribal system of care communities stressed that
adherence to the cultural strengths of Tribal values
becomes the screen through which all services and
fund-seeking decisions must pass. Within this
framework, the written sustainability plan can
clarify financing priorities, outline steps to be
accomplished toward each financing priority area,
list timelines for the completion of tasks, designate
key leadership roles and responsibilities, and detail
benchmarks to monitor progress toward long-term
sustainability of the Tribal system of care.
Political Entities and
Sustainability
Findings
The willingness of those who hold the power and
authority to make funding decisions has tremendous
influence on the financial sustainability of the
Tribal systems of care. The AI/AN systems of care
described the ways in which their sustainability
efforts were impacted by government agencies at
the Federal, State, Tribal, and county levels.
Each Tribal system of care community described
making significant investments of time to increase
the government funding sources’ knowledge about
why system of care services are needed and why
Tribal-driven services increase community access
and produce better outcomes. This work included
providing education about Tribal culture, Tribal
needs, Tribal sovereignty, and the Tribal approach
to child and family services. The Tribal systems of
care became expert in ways to generate political and
policy-level support for their systems of care
through education and relationship building.
Tribal–State relationships varied by State, often for
historical reasons, and community representatives
reported the value of developing partnerships with
key State officials and administrators. Many
community representatives participated in State and
county planning meetings to make Tribal needs
known, but pointed out that Tribal staff time was
limited and travel to State or county planning
meetings was time consuming.
Tribal system of care communities also provided
numerous examples of their efforts to monitor and
influence State health planning initiatives, such as
social marketing efforts to draw policy attention to
Tribal family needs. A further complication is that
several of the Tribal system of care service areas
encompass multiple States, resulting in a
multilayered process of developing relationships
with State administrators and the need to understand
multiple State child-serving initiatives.
Many community representatives discussed the
impact of Tribal politics on their sustainability
planning efforts. Some communities reported that
frequent elections of Tribal government officials
were disruptive to sustainability planning; the Tribal
election process can occur as frequently as every 2
years, and the system of care staff had to repeatedly
provide orientation about the transformative
meaning of “systems of care” to prospective, or
newly elected, leadership. Community
representatives also discussed the impact of
turnover in key Tribal government positions that
lead to a shift in priorities for the Tribe or Tribal
organization. Community representatives
emphasized that Tribal elections sometimes caused
rules to change overnight.
Discussion
Support from those with power and influence over
funding decisions is critical for the sustainability of
any system of care, but the Tribal systems of care
have the additional task of educating funding
sources about their culture and approach to Tribal
services. Tribal systems of care spend a significant
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 6
amount of time explaining what services and
supports work for Tribal families, developing ways
to document the benefits of their service array, and
negotiating strategic alliances that support the
sustainability of their systems of care.
In order to sustain financially, the Tribal system of
care communities must advance each of these areas.
For example, although each Tribal
community is aware of what mix of
clinical and cultural supports works
best for it, there remains a need to
better articulate how the cultural
supports may help advance the
clinical interventions, or how
clinical and/or medical
interventions may help open the
door for increased understanding of
the stabilizing role of cultural
supports. Also, Tribal
academicians, researchers, and
evaluators are interested in better
describing the benefits of a Tribal
service array, but many struggle
with how to describe the intersection of the different
world views represented by clinical and traditional
services. And, while Tribal communities are
experienced in developing tactical alliances, the
ultimate accomplishment of turning allied support
into actual contract dollars remains a challenge.
Developing Sustainable Services
Findings
The Tribal system of care communities described
their efforts to build an array of services that best
responded to the behavioral health needs of their
community. Their inherent knowledge of all things
Tribal (social and cultural lifestyles, spiritual
beliefs, values, communication styles, and
resources) offered a cultural advantage in designing
services to match the local need. In general, not
only do the program names of many Tribal systems
of care reflect the AI/AN value of honoring children
and youth, but their arrays of services reflect that
their culture is the foundation of their services.
Some of the communities addressed an ongoing
workforce shortage in Tribal behavioral health by
investing in training and credentialing programs for
staff to increase the quality of care and to provide
career advancement steps for paraprofessional staff.
In addition, several Tribal
communities were successful in
marketing their training program to
the State, which resulted in
modification of State provider
standards to enable the certified,
Tribal paraprofessionals to meet
requirements for third-party
reimbursement.
These successful partnerships
between the Tribal systems of care
and State governments resulted in
training and education programs that
met State credentialing requirements
as well as the cultural service needs
of Tribal communities. Many Tribal systems of care
encouraged partnership with the State from the
beginning of the curriculum development to ensure
that any obstacles to becoming a State licensed
provider of behavioral health services were readily
addressed and resolved.
Community representatives described successful
partnerships with Tribal community colleges and
universities to develop and provide training. One
community representative noted that while higher
education strengths lie in providing an academic
foundation to behavioral health knowledge, such a
setting may not always be as successful for teaching
the practical skills needed by staff to provide mental
health services. Given the urgent situations of many
Tribal youth, some communities felt that Tribal
system of care staff needed on-the-ground clinical
skills more than academic theory.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 7
The Tribal communities developed a range of
approaches to address the role of culture as part of
the assessment and treatment planning process,
including
■ relying on local cultural advisors to guide the
development of the services;
■ developing extensive cultural assessment
protocols based on the local definition of
wellness;
■ developing treatment goals to include both a
clinical and cultural assessment;
■ setting the pace and location of the “treatment”
according to local culture and individualized
needs;
■ developing Tribal behavioral health training that
benefited both the Tribal practitioner and non-
Native clinical supervisor;
■ incorporating traditional practices into the
“treatment” plan that were individualized
according to particular Tribal beliefs and family
requests.
Many of the Tribal communities discussed their
struggles with determining whether and how to seek
financial support for traditional practices.
Traditional practices can be defined in many
different ways and are an important cultural link to
the healing process. In general, the Tribal systems
of care expressed concern that seeking financial
support for traditional practices might result in
requirements for adhering to licensing and
accreditation standards.
Tribal community representatives suggested various
solutions, which included
■ developing a line item in their system of care
budgets for broadly defined cultural supports,
which might include traditional practices;
■ including references to traditional practices
within their system of care coordinator
certification process;
■ cross-walking the “treatment” goals of Tribal
traditional practices with their clinical outcome
counterparts.
Whether a treatment approach was referred to as a
traditional practice or not, many felt that promoting
culturally competent service provision was just as
important to the sustainability of their system of
care as securing financial resources.
In addition, several communities discussed the
impact of the large infusion of Federal system of
care grant dollars on their program design.
Although the Federal support enabled the
community to pay detailed attention to all elements
of Tribal service provision, a few communities
advised that too much program growth too quickly
could diminish the quality of service provision. That
is, the addition of staff without program
underpinnings in place (e.g., a full orientation to the
system of care framework, training on system of
care service expectations, and an understanding of
how the service array links to outcome measures)
could mean that the newly hired staff were not able
to work effectively as a team of system of care
providers. Therefore, some community
representatives recommended building slowly and
expanding services only to the extent that quality
service provision could be assured.
Discussion
Tribal systems of care are challenged by building
services that can be sustained beyond the Federal
grant. This requires that the system of care
leadership maintain a balance between cultural and
clinical knowledge, address workforce recruitment
and training needs, provide effective supervision
and oversight, and develop meaningful ways to
measure outcomes related to the full range of their
services. Training and education costs are critical
for workforce readiness, and supervision supports
could be an important element of workforce
retention. Another program cost is Tribal
administrative time, essential for building
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 8
relationships and educate funding sources on the
value of Tribal-driven services.
Strengthening Infrastructure
Findings
Each of the Tribal system of care communities was
at a different point on the continuum of
infrastructure development. Those that were part of
a Tribal primary health care organization often had
a reasonably strong infrastructure in place (e.g.,
computerized care management documentation, an
information technology department for computer
trouble shooting, a fully staffed finance and billing
office). Tribal systems of care that were not
attached to a health care system often had to build
their organizational infrastructure from the ground
up. This was complicated by their remote locations,
which hindered their ability to recruit and hire staff
to support their infrastructure development.
The communities discussed how the lack of local
and well organized culture-based services
contributed to the disproportionate numbers of
American Indians and Alaska Natives in juvenile
justice, foster care, child welfare, and behavioral
health systems. Most Tribal communities are rich in
culture, but poor in financial resources. When
funding for services is received in such high need
communities, the immediate focus is on delivering
services to the community. Strengthening the
service system infrastructure often takes a back seat
to mobilizing services to meet the community need.
One community representative suggested that Tribal
communities should take the time to build a solid
administrative and financial infrastructure, one that
is designed for growth. Another community
representative reported that hiring or contracting
with a public accountant to review the Tribal system
of care’s accounting system, billing capacity, and
fund oversight was an essential step in building
such infrastructure.
Community representatives discussed other aspects
of their organizational infrastructure that affected
their system of care, including the following:
Internet. The remote locations of many of the
Tribal systems of care have sporadic Internet
connectivity. This was mentioned as affecting
electronic billing capability and diminishing their
ability to comply with State contract performance
standards, such as those mandating a maximum
time period between when the service was provided
and when the data was input into State databases.
One community that increased its use of electronic
communication found that many members of its
Tribal Council were unfamiliar with the technology,
so that training had to be provided to improve the
Council members’ comfort and skill with computer
technology.
Office space. Office space is extremely scarce for
many Tribal communities, as is housing for newly
recruited staff. Due to a lack of available office
space, several communities reported having
uncomfortable working conditions or offices
scattered across several locations, creating a barrier
in staff unity. To address the lack of space, some
communities received office space from school
districts to provide school-based services. Other
communities built their own facilities. Building
office facilities, which also served as community
centers, was a large part of promoting program
sustainability for these systems of care.
Billing infrastructure. Tribal billing capacity is
critical for many financial sustainability plans, but
many finance staff in smaller Tribal organizations
have a narrowly defined responsibility of meeting
payroll and billing a grant funding source on a
once-a-month basis. Thus, establishing a complex,
third-party billing system can require a huge
investment of resources. Technical assistance from
State representatives was helpful for some to better
understand their billing processes and reduce future
billing errors. Others reported facing the challenges
of insufficient financial software or keeping up with
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 9
necessary software upgrades to meet the changing
requirements of payers. On the other hand, those
that were part of a large Tribal health care
organization reported being able to tap into existing
billing infrastructures, making the transition to
billing for mental health services less challenging.
Staff transformation. Some community
representatives discussed the challenge of
transitioning Tribal direct service staff from a long
history of working within a grant funding
environment, with no uniform expectation for a
specific number of direct service hours per week, to
a billable service hour model. The billable hour
model requires that each staff person work within
specific weekly service expectations that include an
established goal of a certain number of billable
service hours. Transitioning staff into billable hour
performance expectations was successful when the
Tribal organizations turned the billable hour
expectation into a visible team effort that
emphasized increased service to the community.
Discussion
Many Tribal organizations have made important
advances in strengthening their organizational
infrastructure as part of sustainability planning.
Consultation with financial oversight and grants
management advisors has been helpful and has
resulted in a list of action steps to achieve a stronger
infrastructure. Many Tribal systems of care have
gained much support and advice from peer-to-peer
learning opportunities. Establishing relationships
with State funding sources and State contracts
offices has been useful in better understanding data
requirements and billing processes. Tribal systems
of care have gained additional insight by exploring
a State or national accreditation process that
provides a list of action steps to prepare for
accreditation. Continuous awareness of integrating
cultural norms into the infrastructure development
is critical.
Developing a process for continuous quality
improvement (CQI) is another important step
toward financial sustainability. Unless a CQI
process is institutionalized within the Tribal
organization—especially in communities where the
need for services is great and the environment may
frequently be crisis driven—it can be easy to lose
sight of the sustainability plan. Institutionalizing a
CQI process requires the formal allocation of
responsibility for quality improvement to a person
or team with the power and authority to transform
and improve services and financing opportunities. It
is helpful for this person or team to have experience
in managing in a changing environment.
Role of Data in Financial
Sustainability
Findings
The Tribal system of care representatives discussed
general concerns about data collection that reflected
the historical mistrust held by many Tribes. Tribal
hesitation about data collection, ownership, and
analysis is based on the historical misuse and abuse
of Tribal data by some non-Tribal researchers.
However, many community representatives also
recognized the importance of tracking service use
information as part of financial reporting. The
system of care funding legislation requires grant
community participation in a national evaluation of
system of care implementation; some Tribal
communities have used this involvement as a
springboard to further develop their own local
evaluation efforts. Community representatives
emphasized the importance of Tribal “ownership”
of, and a voice in, the data collection and analysis
processes to ensure a cultural interpretation of the
data.
Discussion participants also reported the need to
improve Tribal data systems. Community
representatives from one community stressed the
usefulness of having information on the number of
clients served, the number of services rendered to
each client, the types of services rendered, and
client characteristics. Another community
representative stated that program evaluation cannot
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 10
occur without data and benchmarks. Tribal strategic
planning and system of care coordination is
hindered when basic service information is not
available across the child-serving systems.
Coordination between State reporting systems and
Tribal databases was also reported as a challenge.
One community discussed the double challenge of
using an outdated data tracking system
within the Tribal organization, but also
having to enter data into a complex
State database. Technical assistance
from the State regarding the State
databases proved helpful for one
community, but another community
discussed the need for increased Tribal
advocacy and input into State
decisions about technology upgrades
and electronic reporting requirements.
Tribal–State partnerships in improving
data technology were often successful.
A State discussant described efforts to
help Tribal organizations in obtaining technology
grants to upgrade computer equipment and to
increase the Internet speed for remote Tribal
locations, enabling reports and data for billing to be
transmitted quickly. In this win–win situation, the
State’s motivation was to facilitate Tribal access to
Medicaid billing and data tracking, and the Tribal
organization gained a multipurpose technology
upgrade.
While data collection was reported as being a time-consuming
requirement for the Tribal system of
care, it was also considered essential for justifying
the need for staff positions, revamping program
foci, securing additional funding sources,
negotiating changes with the State for provider
qualifications, focusing staff training on emerging
community needs, and promoting social marketing
endeavors.
Discussion
The system of care national evaluation process is
challenging to some Tribal communities. However,
the communities acknowledged advancements in
the use of data for sustainability planning, program
planning, and organizational change. The ability to
have program managers and evaluators on staff who
became trained and experienced with system and
client outcome indicators,
sustainability assessment measures,
and other aspects of data use was
recognized as valuable.
Although Tribes and Tribal
organizations hold a historical
distrust of data requirements, the
system of care evaluation effort
provides an opportunity for Tribal
communities to build knowledge and
adapt the data requirements in ways
that best support local needs. Tribal
systems of care are at different places
on the continuum of data use, but the
ability to develop data-based arguments for funding
of Tribal services is essential for long-term
sustainability planning.
Assessing and Mobilizing
Funding Sources
Findings
Tribal community representatives expressed
frustration with the scarcity of available funding
sources for their communities. The shortage of
funding for Tribal communities is partly due to
regional economies, confusion about which
government entity is responsible for Tribal services
and omission of Tribal services from funding
applications. One community representative
mentioned the practice of some States and counties
of including Tribal statistics in their overall
statement of need in State and/or county grant
applications, but to provide little funding to Tribal
service providers.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 11
There is a substantial lack of available funding in
rural and remote Tribal locations. One community
reported it had three experienced grant writers on
staff, but the community lacked any funding
opportunities to pursue, especially those that would
support the youth-guided and family-driven values
of a system of care. In another instance, upon the
Tribe’s receipt of the system of care grant funding,
the county within which the Tribe resided stopped
providing all previous funding to the Tribal
community and would not re-establish the financial
support once the CMHS grant funding ended,
despite system of care staff efforts. Communities
were also challenged in finding grants with
sufficient indirect cost funding to support program
administration needs.
To further complicate fund-seeking efforts, some of
the Tribal system of care communities encompass
service areas that are part of more than one State. In
these situations, multi-State political and economic
environments affect the systems of care, requiring
that Tribal communities become knowledgeable
about multiple States’ children’s initiatives,
Medicaid regulations, provider standards, and
credentialing requirements.
Matching Funds Requirement
The Federal system of care funding requires that the
grant community must make non-Federal
contributions toward program costs. Meeting the
Federal cost-sharing requirement (informally
referred to as the match requirement) is consistently
one of the greatest challenges for the Tribal systems
of care. Although the requirement encourages local
investment in the system of care by other child-serving
systems, Tribal communities represent some
of the most impoverished areas of the country. One
community reported that there were not enough
financial resources in the area to meet the match
requirements. Another community addressed this
issue by joining a coalition of Tribes to negotiate
with the Federal Government to have the
requirements waived for the poorest counties in the
country.
Communities stressed the importance of
understanding what can and cannot be used toward
the match requirement under the Federal cost-sharing
guidelines. Although eligible Tribes and
Tribal organizations receiving funds under the Self-
Determination and Education Assistance Act are
exempt from the restriction prohibiting the use of
Federal funds as match, they must ensure that the
funds received under this Act are not being used as
Federal match by other components of the Tribal
organization or Tribal government.8
Those community representatives who reported
having the most success with meeting the match
requirements had long-term relationships with State
or county funding sources; the State or county cash
grants were their match, or cost-sharing, dollars.
Most communities reported meeting the cost-sharing
requirements by assigning a cash value to
in-kind contributions. However, searching for and
documenting in-kind contributions was a labor-intensive
process that pulled time away from direct
services.
Discussion
The Tribal, State, and regional economic
environments that surround the Tribal system of
care have a direct impact on its ability to locate and
access funding support. The fund-seeking challenge
is greatly exacerbated because many of the Tribal
systems of care are located in the most
economically depressed regions in the country. The
shortage of available funding sources makes it even
more important for the Tribal system of care
communities to avoid “chasing” dollars as they
become available. Instead, time spent in developing
a sound strategic plan and a logic model delineating
the community’s theory of change would be well
spent.
8 Tribes receiving funds under the Self-Determination and
Education Assistance Act (PL 93-638, as amended) are
exempt from the restriction that prohibits the use of those
Federal funds as match as long as the funds are not being used
as match for other funding sources.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 12
Analysis and identification of funding sources that
meet the Tribal vision as well as the funding source
vision is a business-smart, strategic
process. This fund-seeking process
should be focused by the
community’s strategic plan for
sustainability that includes a well-thought-
out theory of how the local
community will change from
“service as usual” to a new
framework of a Tribal system of
care. Additional development of
strong financial and contract
reporting systems will not only help
build well-organized and effective
services, but will result in setting the
stage for replication of best service
and infrastructure practices.
Determining the Cost of Services
Findings
A fundamental step in sustainability planning is to
determine the true cost of service provision. One
community’s representatives reported that they
determined the actual cost of their services through
the use of time and cost studies. Using a time study
form, each administrative and direct service staff
person tracked how he/she spent each work day
over a specified period of time (e.g., 2 weeks). The
time study approach categorizes typical activities
and requires staff to record the amount of time spent
in each type of activity. Using this foundation of
information, the actual cost of various services
(including time spent completing client paperwork,
administrative costs, supervision costs,
transportation, etc.) was calculated. With this
information in hand, the Tribal system of care could
then negotiate payment rates with funding sources.
Discussion
Tribal programs that develop a budget or negotiate a
contract without a full determination of the actual
cost of their service provision are fiscally
vulnerable and always in a disadvantageous position
during contract negotiations. Determining an
accurate cost of services is especially critical for
culture-based services because this
type of service usually involves a
longer process for cultural
engagement and usually requires an
expanded amount of time to render
service. Time studies can help
determine the length of time used
for culture-engagement strategies,
and the amount of time needed for
each step of culture-based
treatment. Tribal communities can
then negotiate cost-based rates for
the full range of Tribal services
(e.g., clinical and cultural
assessments, community health aide
services, behavioral health care,
case management), which is critical.
States are interested in ways to reduce the high cost
of some State services and increase their
effectiveness. Negotiating with States for Tribal
service contracts is more effective if Tribal
organizations know the cost of their services and
can demonstrate that their approach to service
provision will not only be less costly to the State,
but will likely result in better outcomes.
Medicaid as a Funding Source
Findings
An essential part of many of the Tribal system of
care sustainability plans included exploration of a
partnership with Medicaid (the largest payer in the
country for behavioral health services). The
Medicaid structure, designed as a shared expense
between the Federal and State governments for
State plan-approved Medicaid services also includes
a special provision for Tribal partnerships.
This provision is related to the Federal share of the
Medicaid service cost, which is referred to as the
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 13
Federal Medical Assistance Percentage (FMAP).9
Several community representatives reported that
they spent significant amounts of time meeting with
State officials to explain the potential benefits of
Tribal–State partnerships and to negotiate access to
reimbursement rates through this special provision
in the Indian Health Care Improvement Act,
through federally qualified health center rates, or
through changes in provider standards that better
support Tribal-driven services.
The exploration of Medicaid access had many
starting places, depending on the organizational
structure and infrastructure capacity of the Tribal
system of care. For example, Tribal communities
that did not already have a national or State license
or accreditation status as a behavioral health
provider first pursued the steps to become licensed
or accredited—a necessary step toward being able
to bill Medicaid for eligible services. Most of these
communities realized that in addition to further
development of their behavioral health policies and
procedures, they also needed to focus attention on
developing their third-party billing capacity. Some
communities became knowledgeable about
Medicaid enrollment standards and explored ways
to co-locate Medicaid enrollment staff in Tribal
community locations.
The potential relationship between traditional
services and Medicaid reimbursement were
addressed in a variety of ways. Traditional services
could be classified as behavior management or
rehabilitation services in some State Medicaid Plans
9 The FMAP rate is based on the State per capita income, thus
varying from State to State; the State share of Medicaid
service costs range from 50 percent to 85 percent. A
Congressional provision of the Indian Health Care
Improvement Act established a match rate of 100 percent
Federal dollars and zero State dollars for Medicaid services
offered through the Indian Health Service (IHS), Public Law
93-638 Tribes, or Public Law 93-638 Tribal organizations. In
addition, the Tribal services must be provided through a
tribally owned/leased and operated facility that is on the
official IHS facility list. If all the requirements are met, this
FMAP option can result in cost savings to States and is one of
that recognized the value of selected traditional
practices as part of the service array. One Tribal
community employed a licensed counselor as a
clinical staff supervisor who provided cultural
services as part of the treatment plan. Some
communities addressed the use of traditional
approaches as part of treatment in their training and
certification curriculum.
Careful analysis of the State Medicaid
reimbursement rates and behavioral health billing
categories was important in Tribal community
service planning, as was the financial calculation of
the number of billable hours per week per staff
person. Some Tribal communities conducted a
crosswalk of the planned Tribal system of care’s
services with Medicaid behavioral health billing
categories to determine categorical alignment. Some
Tribal communities worked closely with State
Medicaid staff and other Medicaid providers to
explore and submit State Plan Amendments to
increase Tribal access to Medicaid services. If
amendments were not possible, continued
collaboration with the State Medicaid office
sometimes led to regulatory changes (e.g., easing of
duplicate paperwork) that facilitated a Tribal system
of care’s involvement as Medicaid providers of
services.
Challenge areas included unsuccessful access to the
State’s behavioral health managed care system and,
hence, unsuccessful access to Medicaid. Some
communities were not able to access Medicaid
services because they did not have licensed staff or
did not offer any billable services at their current
stage of service development. Some communities
were unaware that transportation is a service that
may be eligible for Medicaid reimbursement. This
is unfortunate because transportation is a significant
cost in Tribal services due to limited community
member vehicle ownership, the long geographic
distances to reach services, and the lack of financial
resources for fuel.
the reasons that Tribal systems of care explore Medicaid as a
resource for eligible services.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 14
Discussion
The historical funding resources for Tribal
behavioral health services, primarily Indian Health
Service and Bureau of Indian Affairs, remain too
meager to fully address the growing disparities and
behavioral health needs of local Tribal
communities. Tribal system of care communities
recognize that they must search for additional
financial support, and Medicaid is prominent in
most of the Tribal sustainability plans. Key to
pursuing Medicaid service coverage are several
factors: the ability of the Tribal organization or
Tribal government to develop a working
relationship with State Medicaid officials; the
design and efficacy of the Tribal service array; the
ability to recruit (or develop) a licensed workforce;
and the capacity of the Tribal infrastructure to
effectively support a third-party billing mechanism.
Developing and Sustaining Key
State Partnerships
Findings
The majority of the community representatives
spoke about the value of establishing a working
relationship with a key State administrator that later
became an important part of their sustainability
efforts. The Tribal communities used a variety of
approaches to build relationships with State
administrators, but common to their approaches was
conducting Tribal–State meetings to educate each
other on mutual needs and priority areas and
provide information about the connection between a
cultural foundation to service and improved
outcomes. One community’s strategy was to include
representatives from the county on its Tribal
advisory board to increase their exposure to Tribal
needs.
Some community representatives stressed the need
to start relationship-building with the State as early
as possible, as it could take years to get into the
State system and, ultimately, into the State budget.
Often, the State contact person became a
“champion” for Tribal services—that is, someone
who advocated within the State system for the value
of Tribal services.
The State contacts that were developed also
provided insight into the inner workings of State
system priorities and data systems, which proved
invaluable to several Tribal systems of care. For
example, some State contacts provided training on
how to negotiate a maze of county program
requirements and reporting forms. One State
champion provided assistance in understanding how
to reduce the error rate in Medicaid billing. Another
was helpful in advocating for changes in minimum
provider qualifications for case managers and care
coordinators.
The State champions were valued because they
understood sovereignty rights, valued the Tribal
expertise regarding providing services to Tribal
communities, and understood how Tribal services
could benefit the State. However, some community
representatives observed that the development of
positive relationships with representatives of their
States’ agencies was challenged by State personnel
lack of knowledge about Tribal sovereignty and
historical trauma, lack of trust between the Tribe
and the State, and staff turnover within partnering
agencies and representatives.
Discussion
Developing working relationships with key State
partners can be helpful for Tribal communities that
are trying to expand their funding sources. Tribes
and Tribal organizations that pay particular
attention to Tribal members disproportionately
using high-cost State services can then develop a
data-driven argument for Tribal service contracts.
That is, if the number of Tribal youth in high-cost
State services (e.g., juvenile corrections, non-Native
foster care, residential treatment) continues to be
out of proportion to the percentage of Tribal youth
in the overall State population, the Tribal
organizations can build their argument that
placement of Tribal youth in mainstream
institutions is not only ineffective, but very costly to
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 15
the State. Relationship building with State partners,
combined with demonstration of the effectiveness
of Tribal services, can result in service contracts for
Tribal systems of care.
Implications for Long-Term
Financial Sustainability
Examination of the financial sustainability efforts of
the 15 American Indian and Alaska Native (AI/AN)
system of care communities has resulted in
information that will be useful to Tribal service
planners, Tribal finance administrators, and system
of care funding sources. It is clear that Tribal
sovereignty and Tribal political structures
(including Urban Indian structures) have a
significant impact on financing.
Other factors impact sustainability. Historical
trauma can affect the ability of the Tribal
community to come together for productive
sustainability planning, as well as impact how much
Tribes want to develop a working relationship with
the State or county. Tribal infrastructures (e.g.,
computer technology, finance and billing systems,
and human resources) are critical to implementation
of sustainability plans, but are under-developed in
some Tribal communities. Determining the true cost
of Tribal and culturally based
services is challenging but possible.
Matching fund requirements (non-
Federal cost sharing) remain a
significant challenge in Tribal
system of care communities that
have limited resources.
Implications of the study’s findings
for next steps include the need for
finance-focused training and
technical assistance, broader
dissemination of best practices, and
the importance of peer-to-peer
learning opportunities on a range of
topics such as accreditation, Tribal–
State agreements, Medicaid
negotiations, third-party billing systems, and other
finance-related topics.
The AI/AN system of care communities have made
significant contributions to the field of cultural
competence through their community-engagement
strategies, cultural and clinical assessments,
culturally based treatment plans, and culturally
based services. This report summarizes the Tribal
contributions to the field of sustaining systems of
care through examples of Tribal infrastructure
development, Tribal–fund source relationship
building, and a range of approaches that lead to
financing for culturally based services.
Successful planning for long-term financial
sustainability
■ is a strategic process that starts early;
■ is facilitated by proactive leadership;
■ builds on a strong and stable infrastructure;
■ ensures that the system of care theory of change
is integrated into fund development plans;
■ builds collaborative relationships with national
and local Tribal resources.
The development of financial relationships that
meet serious Tribal community needs can benefit
from quality cross-cultural
communication; respect for Tribal
self-determination; understanding of
mutual financial needs,
opportunities, and restrictions; data-driven
and anecdotal understanding
of the urgency of Tribal community
needs; and a commitment to
decrease reliance on ineffective
service systems that are not working
for Tribal families.
Following are recommendations for
each of the financing and
sustainability subject areas
discussed in this report.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 16
Recommendations for Financing and Sustainability
in American Indian and Alaska Native
System of Care Communities
Planning for Sustainability
■ Begin planning for long-term financial
sustainability on the first day of the system of
care grant (or even before actually receiving the
grant), taking care to build planning on the
foundation of local cultural strengths.
■ Create a sustainability planning team that
includes key decision makers (e.g., Tribal
elected officials or Tribal administrators who
have the authority to make the needed changes,
Tribal program planners, and Tribal finance
staff).
■ Ensure active involvement of Tribal youth and
family members at the planning table, and
examine and resolve the cultural basis of any
resistance to their active leadership.
■ Use the system of care grant requirements
categories as a guide to developing a framework
for Tribal planning efforts.
■ Review the Tribal Constitution, Tribal Codes, or
the Tribal organizational mission statement for
compatibility with key system of care
principles; use the constitution, codes, or
mission statement as the mechanisms through
which the system of care transformation goals
can be met.
■ Determine the readiness of the local Tribal
offices and Tribal programs to understand and
willingly adhere to system of care values and
principles. If needed, develop a system of care
orientation for Tribal members that explains a
system of care in simple terms; use local
cultural concepts as examples.
■ Work with Tribal leadership to examine Tribal
financial capacities and resources for long-term
sustainability strategies.
■ Determine ways to incorporate the system of
care sustainability plan into the broader Tribal
financial planning; if barriers exist, discuss with
Tribal leadership ways to create a cohesive
system of care team across Tribal programs,
Tribal offices, and other Tribal resources.
■ Discuss how local Tribal values and beliefs fit
with a logic model concept and/or contribute to
the description of the Tribal theory of change.
■ Use a logic model-planning tool that best fits the
Tribal community to combine all needs
assessment and service design information into
a sustainability plan; update the plan annually
and make sure the plan is tied into the
timeframe of the overall Tribal planning
process.
Interacting With Political Entities
Regarding Financing
■ Determine who makes funding decisions within
the Federal, State, Tribal, and county
governments; determine how funding decisions
are made within these entities.
■ Assign a point person, or join a Tribal coalition,
to follow the development of State legislative
health policy and/or State administration
regulatory processes for proactive planning.
■ Stay alert to the annual or bi-annual Tribal,
State, and county budget-building processes and
make sure decision makers are aware of system
of care operational and non-Federal match
needs.
■ Build an educative relationship with Tribal
elected officials, key State Legislators, and other
local policymakers, taking care to stay in
contact on a regular basis throughout the year
and not just during a financial crisis.
■ Build alliances with Tribal elected officials,
Tribal service administrators, and/or Tribal
governing boards; negotiate inclusion of the
Tribal system of care as a standing agenda item
on the Tribal governing board agenda and
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 17
provide ongoing updates on the system of care
transformation and child and family
improvements.
■ Meet with candidates for Tribal elected offices
and orient them to the system of care approach
to services, the meaning of system of care
transformation, and budget needs.
■ Develop a data-driven argument for the need for
Tribal system of care funding, emphasizing
human and financial cost-savings by
redeploying funds from high-cost State services
that tend to be less effective to lower-cost Tribal
services that tend to be more effective.
■ Develop a cultural competence argument for
Tribal services, linking culturally competent
service provision with increased access to
services and improved child and family service
outcomes.
■ Develop a Tribal–State workgroup to examine
the over-representation of Tribal people in child
welfare, juvenile justice and education, and to
propose solutions for the elimination of
disparities.
■ Participate in Tribal, State, and county planning
meetings and present Tribal behavioral health
needs and cost-effective services that meet those
needs; request statutory or fund-shifting changes
to support the Tribal system of care.
■ Develop and/or participate in a Tribal–State
Medicaid workgroup and develop working
relationships with Tribal Medicaid liaisons.
Developing Sustainable Services
■ Conduct a planning retreat or process to
convene with key community stakeholders to
determine a local definition of wellness and to
describe how Tribal traditional culture and other
cultural influences impact access, services
provision, and service outcomes.
■ Design a cultural approach to services
(individualized for each family) that includes
strengths-based language; a cultural assessment
component of the clinical assessment; treatment
goal setting that includes attention to the role of
culture in wellness; treatment benchmarks that
include cultural strengths; and outcome
measures that show how attention to culture can
improve treatment outcomes.
■ Review traditional practices used in the
community for healing and stabilization
purposes and review the therapeutic aspects of
traditional practices (e.g., some traditional
practices may help resolve grief); cross-walk
these therapeutic practices with State-approved
behavioral health billing categories.
■ Meet with State representatives to discuss Tribal
services and any changes that are needed in
provider qualifications (e.g., expanding
Targeted Case Management to include a
provision for Tribal providers, modifying State
educational requirements for becoming a
licensed Tribal behavioral health provider).
■ Develop a staff-training curriculum based on
local Tribal values and local Tribal service
design to advance staff service skills and
credentials; meet with the State credentialing
board for licensed behavioral health providers to
discuss the Tribal curriculum concept to ensure
that the State licensing board will approve the
Tribal curriculum.
■ Partner with Tribal colleges and the State
credentialing program to implement a Tribal
system of care training and education program.
■ Develop a training plan for program managers,
clinical supervisors, and other program
management staff to ensure their knowledge is
current regarding managing change in complex
environments, staff supervision, staff
development, contract oversight, and financing
strategies.
Strengthening Infrastructure
■ Conduct a scan of infrastructure needs by
reviewing the list of system of care grant
requirements and any fundraising goals to
determine if the Tribal program has appropriate
• physical buildings and adequate service
locations;
• space for individual and family services that
meet privacy requirements;
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 18
• group space for community activities;
• office furnishings that reflect
professionalism and offer family comfort;
• clinical tools and equipment for service
provision;
• cultural tools and equipment for service
provision;
• adequate computer hardware for
communication, reporting, and training;
• functional computer software that meets
day-to-day communication and reporting
needs, including data tracking and
accounting needs;
• consistently available computer technology
staff for trouble shooting and repair;
• personnel policies and procedures, job
descriptions, and salary scales;
• policies and procedures for services, grants
management, and fiscal controls;
• billing manuals.
■ Consider hiring a Certified Public Accountant to
review current financial systems and to make
recommendations for improvement and further
development.
■ Develop and implement infrastructure
development plan that supports service growth
and includes actions steps and timelines; ensure
that it is framed within the broader context of a
Tribal logic model or theory of change.
■ Assess the feasibility of becoming a State-licensed
or nationally accredited organization by
reviewing the accreditation options, examining
the fit with the Tribal belief system, determining
the overall benefits and drawbacks to licensing
and/or accreditation, determining whether the
cost of pursuing accreditation is feasible, and
determining whether the Tribal system of care
has administrative staff available to lead the
accreditation team.
■ Upgrade billing and data reporting software
after determining if the purchase of new
software is cost effective when compared to the
volume of Tribal data processing needs.
■ Implement third-party billing capacity,
including the training and supervision needed to
transition from grants management to a third-party
billing system.
■ Overcome Tribal staff resistance to increased
documentation requirements by using Tribal
supervisors for professional modeling, oversight
and helping Tribal staff understand the
relationship between third-party billing, budget,
and increased services for the community.
■ Conduct computer skill development training
for Tribal Council or Tribal governing board
members for increased communication and
access to resources.
■ Conduct a site visit to another Tribal system of
care that has successfully implemented a
sustainability strategy, for a peer-to-peer
learning opportunity.
■ Work with Tribal administrators to ensure that
all internal systems (e.g., fiscal, technology,
management, human resources, training)
interlock, maintain close communication with
each other, and share a common goal of
advancing the Tribal system of care.
Using Data in Financial
Sustainability Planning
■ Discuss with Tribal leadership any concerns or
questions about data use and clarify the Tribal
stance on data collection, data analysis, and data
ownership.
■ Provide orientation on Tribal system of care
data use for Tribal elected officials, Tribal
governing board members, and Tribal
administrators; link data use examples to client
progress, program planning, fund development,
and contract negotiations; and emphasize ways
that Tribal data use can support Tribal self-determination
and data-driven decision making.
■ Discuss Tribal capacity for, and affiliated costs
of, a sustained data collection and data analysis
process and allocate resources for
implementation.
■ Develop data-driven arguments to support
inclusion of Tribal services in fund opportunity
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 19
language and regulatory changes to funding
processes (e.g., ways to increase Tribal access to
Medicaid reimbursement of services).
■ Determine the role of Tribal data in program
evaluation, sustainability planning, and contract
reporting.
■ Visit a Tribal system of care that has been
successful in using data for a peer-to-peer
learning opportunity.
■ Analyze aggregate data to demonstrate youth
and family improvements and related human
and financial savings.
■ Identify existing Tribal and non-Tribal data
sources that may be useful for the sustainability
planning process.
■ Advocate that State technology decisions related
to data transmission requirements must be
consistent with the technology capacities of
Tribal communities.
Assessing and Mobilizing
Funding Sources
■ Conduct a financial environmental scan and list
all funding sources in the State or region that
support Tribal children and youth; determine
which funding sources the Tribal system of care
is not accessing, and list the reasons why the
system of care has not been able to access these
sources.
■ As part of building a case for funding, compare
the percentage of the Tribal youth population in
the State with the percentage of Tribal youth in
State or county services (e.g., juvenile justice,
child welfare, residential treatment).
■ Develop data-driven funding arguments by
determining the monthly (or yearly) cost of
State, county, and private institutional care and
comparing these costs to the cost of Tribal
services.
■ Imbed the Tribal system of care sustainability
plan into all aspects of the Tribe or Tribal
organization’s overall fund development and
business operations.
■ Write a business plan for the system of care.
■ Follow the development of behavioral health
policy in Indian Health Service (IHS) and the
State legislature, or any State regulatory
discussion of existing behavioral health policy;
participate in State planning meetings as much
as possible to track and influence evolving State
initiatives and ensure that Tribal needs are
included in legislative language.
■ Develop an accreditation team to assess the
organization’s ability to complete required steps
toward State behavior health licensure and/or
national behavioral health accreditation.
■ Explore the financial feasibility of out-of-the-box
financing ideas such as developing a
business arm of the non-profit corporation.
■ Clarify what can and cannot be used as match
under the Federal cost-sharing guidelines, with
particular attention to understanding the
exemption for eligible Tribes and Tribal
organizations, which allows use of certain
Federal funds as match.
■ Develop annual goals for in-kind contributions
and local non-Federal cash contributions;
monitor all match goals on a monthly or
quarterly basis.
■ Create a list of potential in-kind contributions
(e.g., space donations, pro bono consultation)
and non-Federal cash resources (e.g., State
grants, private foundation grants).
■ Develop processes to document in-kind
contributions and the assignment of cash value
to contributions.
Determining the Cost of Services
■ Determine if the Tribe or Tribal organization is
currently using, or has previously used, a cost
study process; if necessary, seek advice from a
cost-study-experienced Tribal organization or an
Indian health planning board.
■ Determine a timeframe to implement a cost
study.
■ Provide an orientation of cost study expectations
for Tribal administration, governing board, and
staff.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 20
■ Determine the actual service and administrative
costs of the full range of Tribal behavioral
health and support services, including the costs
for administrative and supervisory time, staff
training, transportation, home visits, and
traditional practices (i.e., conduct a cost study).
■ Ensure that cost formulas address the costs of
delivering services in remote Tribal areas,
including time spent in cultural translation of
services; computer technology development and
computer training (especially related to cultural
application of service); rural Internet challenges;
cultural-based telemedicine consultation; and
off-site supervision due to the geographic range
of Tribal service locations.
Determining the Feasibility of
Medicaid as a Funding Source
■ Work closely with the Tribal government or
Tribal organization to determine the percentage
of the local Tribal population that is eligible for
and enrolled in Medicaid services.
■ Meet with Tribal administrators or the Tribal
governing board to discuss any community
perception that participation in the Medicaid
program would result in loss of IHS benefits;
consider a public community meeting to clarify
any confusion.
■ Consider negotiating the co-location of State
Medicaid enrollment staff at the Tribal location.
■ Review Tribal services, including traditional
practices, for compatibility with Medicaid
behavioral health billing categories.
■ Consider including access to Medicaid funding
as part of the Tribal sustainability plan and
outline the steps to becoming a State Medicaid
provider.
■ Develop a close and ongoing working
relationship with the State Medicaid office to
increase Tribal access to information about
Tribal enrollment strategies, provider standards,
eligible services, and billing process.
■ Meet with State Medicaid and Tribal health
representatives to determine if the 100% Federal
Medical Assistance Percentage (FMAP) option
is being fully utilized.
■ Meet with State Medicaid representatives to
discuss the development of a Tribal services
section in the State’s provider billing manual.
■ Join a coalition of Tribes in the State to explore
a waiver to the State Medicaid Plan to support
Tribal services and system of care partnerships.
Developing and Sustaining Key
State Partnerships
■ Invest in educating State officials and State
funding source administrators about the Tribal
system of care.
■ Recognize that there may be steep cultural
learning curves for Tribal and State
representatives about their respective service
systems.
■ Develop relationships with Tribal champions
within State government (e.g., non-Tribal State
administrators who acknowledge the value of
Tribal services) and provide them with
information on how Tribal-operated services
can result in positive service outcomes.
■ Ensure that the Tribal organization has the right
person at the right table; for example, send a
Tribal staff person with decision-making
responsibility to a Tribal–State meeting if
decision-making authority is needed.
■ Recognize the multiple influences on the
development of positive Tribal–State
relationships, including historical trauma and
key staff turnover at the State and in the Tribe.
■ Recognize that both States and Tribes are
concerned about the financial cost of ineffective
services and the resulting human cost to both the
Tribe and the State.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A1
APPENDIX A. Understanding the Challenge: The Cultural
Framework
Although the system of care principles and
Tribal belief systems are very much aligned,
Tribal systems of care continue to face
unparalleled challenges in developing and
implementing financing strategies for
sustainability. This is due to many reasons,
including the lack of knowledge by potential
funding sources, such as States, of the
advantages of working with Tribes, the impact
of Tribal–State history on the willingness and
ability to pursue financial partnerships, and the
lack of financial resources in remote Tribal
communities. Adding to the complexity of the
challenge is
■ the history of confusing and contradictory
Federal policies about support for Tribal
services;
■ the meaning of sovereign status of federally
recognized Tribes as it relates to financing;
■ the financial options of Tribes that are
recognized by States but lack Federal
recognition;
■ the role of Tribal self-determination and the
financial implications of Tribal assumption
of services that were previously provided by
Federal agencies.
All of these challenges are further deepened by
a lack of cross-cultural and cross-system
problem solving when partnership barriers arise.
The result are complicated jurisdictional and
policy conditions that exist between Tribes,
Federal, and State governments with many
implications for financial strategic planning.
Negotiation for financial partnership must often
start with the education of Federal, State, or
private funding sources about the relationship
between a cultural foundation to services and
improved outcomes; the impact of Tribal
sovereignty on financial partnerships; and the
values and decision-making processes of Tribal
governments, Urban Indian organizations, and
Tribal nonprofit organizational structures.
Mental health services for the American Indian
and Alaska Native (AI/AN) population are
widely documented as inadequate to provide for
the needs of the people. There are a number of
reasons for the shortage of services: the annual
Federal budget for the Indian Health Service
(IHS) is under-funded by an estimated 40–60
percent of the need for care; only 7 percent of
the IHS budget is allocated for mental health
services; a large percentage of AI/AN people
live in remote rural areas where behavioral
health services are not routinely available; and
Medicaid and other third party payers often
exclude Tribal providers from participation in
mental health networks, do not purchase the
types of services offered by Tribal health
providers, or Tribal providers are unable to
employ the types of clinical providers necessary
to render billable services.
These disparities combined with the economic
conditions in Indian country result in a
disproportionate representation of the AI/AN
population in social service programs, juvenile
and adult detention facilities, and treatment
facilities for mental health and substance abuse
problems. Thus, the impact on Federal- and
State-funded programs is also disproportionate
to the population. Statistics demonstrate that
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A2
mainstream efforts to address health, social and
economic issues in Indian country are
ineffective in addressing the root causes of these
problems. State government programs,
particularly in States with large Native
American populations, are recognizing these
costs and have become interested in partnering
with Tribal organizations for community based
service delivery.
Tribal Entities in the United
States
American Indian and Alaska Native people have
long demonstrated a high level of resilience and
have retained, or re-established, the traditions
and beliefs that serve as their cultural core.
Hundreds of Tribes continue to thrive and
remain culturally and politically unique in the
United States. Each Tribal group is organized
according to historical and cultural influences
(e.g., Tribe, Band, Nation, Pueblo, Village,
community, corporation). The Federal
Government holds special trust obligations
towards Tribal members to provide basic social,
medical, and educational services. The statutes
and treaties under which Tribal communities are
organized have a direct influence on their
financial sustainability options.
Recognition Status
More than 560 federally recognized Tribes exist
in the United States. Federally recognized
Tribes hold a government-to-government
relationship with the Federal Government.
Nearly one-half of the federally recognized
Tribes are in Alaska.
Tribes with Federal recognition status are legal
sovereign nations. Federally recognized Tribes
are rare and distinctive as they function as
independent nations within the nation of the
United States. Therefore, a unique legal and
political relationship exists between the Federal
Government and Indian Tribes. (Similarly, a
special legal relationship exists between the
Federal Government and Alaska Native
Corporations.) This relationship is grounded in
the U.S. Constitution, treaties, statutes, U.S.
Supreme Court decisions, and Federal laws and
regulations. The relationship between the
Federal Government and Tribes is also
grounded in political, legal, moral, and ethical
principles. It is important to note that the
relationship is not based upon race, but is a
government-to-government relationship.
The U.S. Department of Health and Human
Services (DHHS) has a formal consultation
policy with Tribes. Consultation with AI/AN
Tribes must occur to the extent practicable and
permitted by law before any action is taken that
will significantly affect the Tribes. In short, any
DHHS policy requires consultation with Tribes
before action by the Federal Government is
taken if the policy substantially and directly
affects one or more AI/AN Tribes; the
relationship between the Federal Government
and Tribes; or the distribution of power and
responsibilities between the Federal
Government and Tribes.
The legal and political power of sovereignty is
deep. As sovereign nations, Tribal governments
have the right to hold elections, determine their
own citizenship, and consult directly with the
Federal Government on policy, regulations,
legislation, and funding. Tribal governments can
also create and enforce laws to govern their
Tribal members. Tribal laws can be stricter or
more lenient than State laws, but they are not
subservient to State law. State laws cannot be
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A3
applied to a Tribe if the laws interfere with the
right of a Tribe to make its own laws protecting
the health and welfare of its citizens, or if they
would interfere with any Federal interest. Tribal
district courts and supreme courts can be
established to administer justice in criminal,
civil, and juvenile matters. Tribal tax
commissions, economic development
corporations, environmental protection
agencies, public works, and gaming
commissions are other examples of entities that
may be part of a Tribal government structure.
In addition to the federally recognized Tribes,
there are 245 Tribes whose lands and rights are
recognized solely by the State. A State-recognized
Tribe is an Indian Tribe that does not
have a recognized relationship with the Federal
Government through historic treaty,
Congressional act, or administrative process, but
is recognized as a Tribe by the government of
the State in which members reside or are
historically based. A lack of Federal recognition
limits the capacity of State recognized Tribes to
fully govern themselves, seek compensation for
previous loss of land, or be eligible for certain
Federal benefits and funds designated for
federally recognized Tribes. Many State-recognized
Tribes are seeking formal Federal
recognition.
Another important segment of the Tribal
population is the Urban Indian community.
‘Urban Indians’ is a term used to describe
American Indians and Alaska Natives, or
descendents of American Indians and Alaska
Natives, who have moved from their Tribes to
cities or urban areas, either voluntarily or
through forced Federal Government relocation
programs.1 Poverty and lack of economic
opportunities also contribute to the movement of
Tribal people from reservations to cities or
urban areas. More than 60 percent of all Tribal
people in the United States now live in cities or
urban areas and they remain part of the
congressionally mandated trust responsibility.
Regardless of Federal or State recognition, or
Urban Indian status, each Tribal community
reflects a distinct culture, belief system and,
often, Native language. Despite these
differences, common across all Tribal people is
a deeply ingrained sense of respect and honor
for their children (as illustrated by the names
selected for their systems of care). Many Tribal
systems of care program names reflect the
Tribe’s special recognition of children and
youth and the principal role that culture plays as
the foundation of their services.
American Indians and Alaska Natives live
within the complex and overlapping worlds of
Tribal, State, and Federal Governments—each
of these entities has unique laws, manners of
conducting business, and interpretation of
sovereignty. The relationships between Tribes
and the Federal Government, and Tribes and the
State in which they are located, are constantly
evolving. The role of Federal trust
responsibility, sovereign Tribal governments,
interpretation of Tribal and State laws, the
Urban Indian relationship with urban and Tribal
services, and the overall changing needs of
Tribal communities add to this changing
environment. All of these are key factors
affecting the financial relationships and
collaboration between Federal, State, County,
1 National Council of Urban Indian Health (2007). Fact
Sheet. Retrieved January 2008 from
http://www.ncuih.org/Fact%20Sheet.pdf
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A4
and other funding sources and Tribal
communities.
Impact of Federal Policies
Federal Government policies related to Tribal
affairs have fluctuated from open warfare to
later attempts to assimilate Tribal people into
mainstream society, from termination of Tribal
rights to later restoration of Tribal rights, and
from attempts to limit Tribal government to
later compliance with Tribal government self-determination.
These inconsistencies have
created a legacy of policy confusion that
continues to affect Tribal–Federal and Tribal–
State relationships and financing strategies
today.
A strength of the Tribal financing picture is the
Indian Self-Determination Act (Public Law 93-
638), which gives authority to Tribal
governments to assume the budget and
operations of programs and services that had
been previously carried out by the Federal
Government. This not only supports Tribal self-determination,
but also reflects support for
culturally competent practices and community
ownership. The Indian Self-Determination Act
provides the legal framework for federally
recognized Tribes and Tribal organizations to
assume the budget and operations of services
previously provided by the Federal Bureau of
Indian Affairs or the IHS. A Tribe or Tribal
organization that enters into a 638 agreement
with the Federal Government is referred to as a
“Tribal 638 organization” in this report.
Importance of Sustainability
Shediac-Rizkallah and Bone suggest three
reasons why program sustainability is
important.2 First, if a program ends while there
is still a need for services, rates of people with
untreated needs may regress to pre-intervention
levels. This is important when considering rural
AI/AN communities, which likely have limited
mental health agencies and may depend heavily
on the contributions of each agency.3 Second,
programs often incur significant start-up costs in
human, technical, and monetary resources, only
to have funds removed before a program has
reached its fullest potential. This is especially
relevant to Tribes that may have no health care
infrastructure at program start-up resulting in a
need to design an unfamiliar program,
implement major computer technology
upgrades, develop a third-party billing structure,
or provide additional training for staff who are
cultural experts but do not meet the higher
education requirements established by State or
national accreditation bodies. Third, program
sustainability promotes community investment
in future community programs and lack of
sustainability may lead to community confusion
toward future programs. Community support is
essential to the existence and persistence of
Tribal community mental health programs due
to the collectivistic orientation of AI/AN
communities.
2 Shediac-Rizkallah, M. C. & Bone, L. R. (1998).
Planning for the sustainability of community-based health
programs: conceptual frameworks and future directions
for research, practice, and policy. Health Education
Research, 13, 87–108.
3 Jim, N. (2004). The morning God comes dancing:
Culturally competent mental health and HIV services. In
Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental
health for Native Americans. New York: Altamira Press.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A5
Interest in the topic of system of care
sustainability has reached new peaks in the past
few years. Several studies have been developed
to examine aspects of system of care
sustainability. In their work, The Sustainability
of Systems of Care for Children’s Mental
Health, Stroul and Manteuffel discuss the
sustainability study undertaken by the National
Evaluation Team.4 The development of the
Web-based survey included an examination of
the various definitions of sustainability.
Emphasized was the acknowledgement that
adopting the system of care approach for the
long term requires a “sea change” in policy,
clinical practice, and administration of
children’s mental health systems and
maintenance of all of these elements of systems
of care in the face of budgetary challenges and
changing political environments. The University
of South Florida Research and Training Center,
in partnership with the National Technical
Assistance Center for Children’s Mental Health
at Georgetown University, the Human Service
Collaborative of Washington, DC, and Family
Support Systems, Inc., of Arizona, initiated a
study titled “Financing Strategies and Structures
to Support Effective Systems of Care.” The goal
of the study is to develop a better understanding
of the critical financing structures and strategies
that support systems of care. Seven critical
financing strategies are being examined and a
series of guides have been developed. None of
these studies is focused specifically on AI/AN
financing. Although the findings of these studies
provide a framework of sustainability issues
relevant to any system of care community, none
of the studies address in detail the cultural,
4 Stroul, B.A., Manteuffel, B.A. (2007). The
Sustainability of Systems of Care for Children’s Mental
political, and economic issues that are specific
to AI/AN communities and that have a direct
impact on their long term sustainability.
The cultural importance of program
sustainability must not be ignored.
Sustainability of community mental health
programs within Tribal communities is
especially important to empower and avoid re-victimization.
Lucidly expressing this point, one
leader of a Tribal community-based substance
abuse prevention and intervention program
stated,
We have a responsibility to our program
recipients. They’ve had so may losses in their
lives, and [if we] come in for a year or two or
three and give them hope, only to have the
program go away, we’ve just caused another
loss and further hopelessness in their lives.5
The 400 years of persecution, genocide, and
forced assimilation experienced by Native
Americans have led many to experience a
perception of great loss leading to anxiety and
depression or anger and avoidance.6 These
psychological consequences have been termed
“historical trauma.” It is hypothesized that
program sustainability can function to combat
such trauma by empowering Tribal communities
to decrease reliance on outside support and
Health: Lessons Learned. Journal of Behavioral Health
Services & Research.
5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing
substance abuse in American Indian and Alaska Native
communities: The Healthy Nations Initiative. In
Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental
health for Native Americans. New York: Altamira Press.
6 Whitbeck, L. B., Adams, G. W., Hoyt, D. R., & Chen,
X. (2004). Conceptualizing and measuring historical
trauma among American Indian people. American
Journal of Community Psychology, 33, 119–130.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A6
foster a sense of pride in being able to care for
their own community.
Factors Affecting Sustainability
Program sustainability at every level can be
impacted by the effectiveness of critical
sustainability factors. Mancini and Marek have
developed seven key elements critical for
program sustainability: (1) competent leadership
to develop a program’s vision and provide staff
training; (2) effective collaboration with
community members and key stakeholders; (3)
understanding of community needs and
resources; (4) program results demonstration;
(5) strategic funding; (6) staff involvement and
commitment to sustainability; and (7) program
responsiveness to a community’s changing
needs.7 While it is clear that many variables
interact to affect sustainability, underlying each
of these components is the need to understand
the culture of a population served. For example,
effective collaboration with Tribal community
members will be facilitated through a program
leader’s ability to integrate Tribal culture into
the development of a program’s vision. Further,
program response and results demonstrated
within an AI/AN community hinges on a
programs’ ability to provide culturally
competent care.8 Finally, obtaining long-term
financial support requires knowledge of the
resources both within Tribal communities and
outside of the Tribal community. Following are
brief discussions of key sustainability factors
known to affect program sustainability among
Tribal programs.
7 Mancini, J. A., & Marek, L. I. (2004). Sustaining
community based programs: Examination of relationships
between sustainability factors and program results.
Family Relations, 53, 339–347.
8 LaFromboise, T. (1988). American Indian mental health
policy. American Psychologists, 43, 388–397.
Economic and Political Environments
In 2000, the AI/AN poverty rate was 26 percent,
twice the national rate and greater than that of
any other ethnic group.9 Socioeconomic
conditions vary from Tribe-to-Tribe and in
different regions of the country. Some Tribal
system of care communities report
unemployment rates as high as 80 percent in the
local Tribal population. The Center for Disease
Control also mentions geographic isolation,
cultural barriers, and economic conditions as
barriers that contribute to poorer health
outcomes.10 Other studies have focused on
Tribal income increases associated with the
legalization and institution of casino gambling
for the effects on aspects of American Indian
well-being, including the effects on poverty
levels, medical care, and risk-taking behavior,
all of which are indirectly associated with health
status.11 The political environment of Tribes and
Tribal organizations is complicated; sovereign
nation status, and the Alaska Native Claims
Settlement Act (1971) which promised 44
million acres and $1 billion to Alaska Natives,
are examples of the unique aspects of the AI/AN
political environment.
9 Centers for Disease Control and Prevention.
(2003).Surveillance for health behaviors of American
Indians and Alaska Natives: Finding from the behavioral
risk factor surveillance system, 1997-2000. Morbidity and
Mortality Weekly Report. 52, 1. Retrieved January 20,
2008 from http://www.cdc.gov/mmwr/preview/
mmwrhtml/ss5207a1.htm
10 Rural Assistance Center (2008). Tribal health
frequently asked questions. Retrieved January 5, 2008
from http://www.raconline.org/info_guides/tribal/
tribalhealthfaq.php
11 Taylor, J. B., Kalt, J. P. (2005). Cabazon, The Indian
Gaming Regulatory Act, and the Socioeconomic
Consequences of American Indian Governmental
Gaming–A Ten-Year Review. American Indians on
Reservations: A Databook of Socioeconomic Change
between the 1990 and 2000 Censuses. Cambridge, MA:
The Harvard Project on American Indian Economic
Development.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A7
The Harvard Project on American Indian
Economic Development, at Harvard
University’s John F. Kennedy School of
Government, aims to understand and foster the
conditions under which sustained, self-determined
social and economic development
are achieved among American Indian nations.
At the heart of the Harvard Project research
program is the systematic, comparative study of
social and economic development on American
Indian reservations. Relevant for the Tribal
system of care communities are their key
research findings:
■ Sovereignty Matters. When Native nations
make their own decisions about what
development approaches to take, they
consistently out-perform external decision
makers—on matters as diverse as
governmental form, natural resource
management, economic development, health
care, and social service provision.
■ Institutions Matter. For development to take
hold, assertions of sovereignty must be
backed by capable institutions of
governance. Nations do this as they adopt
stable decision rules, establish fair and
independent mechanisms for dispute
resolution, and separate politics from day-to-day
business and program management.
■ Culture Matters. Successful economies
stand on the shoulders of legitimate,
culturally grounded institutions of self-government.
Indigenous societies are
diverse; each nation must equip itself with a
governing structure, economic system,
policies, and procedures that fit its own
contemporary culture.
■ Leadership Matters. Nation building
requires leaders who introduce new
knowledge and experiences, challenge
assumptions, and propose change. Such
leaders, whether elected, community, or
spiritual, convince people that things can be
different and inspire them to take action.
The Native Nations Institute is an outgrowth of
the Harvard Project on American Indian
Economic Development and serves as a self-determination,
development, and self-governance
resource to Indigenous nations. For
more than 15 years, the Harvard Project and the
Native Nations Institute researchers have
worked systematically to understand the
conditions under which sustained economic
development can be successful on American
Indian reservations in the United States and
among First Nations in Canada. These findings
indicate that, while a number of things
contribute to initiating and sustaining
reservation economic development, five are
particularly important:
■ Practical Sovereignty (genuine decision-making
power)
Native nations that have been willing and
able to assert self-governing power over
their affairs and resources have significantly
increased their chances of sustainable
economic development.
■ Capable Governance (effective governing
institutions and practices)
Sovereignty is not enough to produce
economic growth unless those rights and
powers are exercised effectively; the
chances of sustainable development rise as
Native nations put in place effective,
nonpoliticized, dispute-resolution
mechanisms that can shut down
opportunistic behavior by politicians, place
buffers between day-to-day business
management and political decisions or
interference and build capable
bureaucracies.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A8
■ Cultural Match (fit between governing
institutions and political culture)
Effective Trial governing institutions require
legitimacy with the people whose future is at
state, rooted in the fit between the formal
institutions of governance and the
indigenous conceptions of how authority
should be organized and exercised.
■ Strategic Orientation (decision making
that takes strategic considerations into
account)
Successful Native nations tend to approach
development not as a quick fix for poverty
but as a means of building a society that
works, considering long-term priorities and
concerns as well as assets and opportunities,
and bring strategic criteria to bear on
development decisions.
■ Leadership (individuals and groups who
recognize that fundamental change may
be necessary, and who can envision a
different future and persuade the
community to join them)
Successful Native nations have some group
or set of individuals who recognize the need
for fundamental change in a way things are
done; they have a vision of a future of
assertive, capable, effective self-determination
and self-governance, and can
bring the community along with them in
building that future.
In addition to these findings, gaining
community consensus on the approach to Tribal
system of care sustainability can be
complicated. Tribal systems of care often
operate within multiple governing structures
that must work together in sustainability
planning. The Tribal governing structure may
have frequent elections of Tribal officials that
result in leadership turnover and starts and stops
in sustainability planning. All of the variables
discussed, exacerbated by health disparities,
affect the AI/AN sustainability planning
process.
Planning
Planning and infrastructure development
assistance has been available for years to some
Tribal communities through the Federal
Infrastructure Development for Children’s
Mental Health Systems in AI/AN Communities
Initiative, more commonly known as the Circle
of Care Initiative. Available through a
competitive application process, the Circle of
Care Initiative supports AI/AN communities
with funding and technical assistance to plan,
design, and assess the feasibility of a culturally
respectful mental health system of care. The
Circle of Care Initiative provides 3-year grants
to State and federally recognized Tribes, Urban
Indian organizations, Tribal colleges and Tribal
universities. Successful applicants gain
community planning tools and resources to
design a holistic, community-based system of
care to support mental health and wellness for
their children, youth and families. Nearly half of
the Tribal system of care communities had
previously received a Circle of Care planning
grant that enabled them to conduct an in-depth
analysis of the existing infrastructure of the
local child-serving system to identify policy,
service gaps and potential resources, and to
facilitate culturally respectful strategic planning
activities. Also important to the Circle of Care
planning process is community-wide
engagement, development of Tribal logic
models, and development of a local evaluation
process.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A9
Partnerships
Tribal leader hesitancy to develop State or
Federal partnerships is often based in historic
distrust. Broken treaty agreements, conflicts
over land or water rights, and the removal of
Tribal children from their homes to be raised in
non-Indian boarding schools or non-Indian
foster care homes are just some of the reasons
for Tribal partnership hesitancy.
State motivation to pursue partnerships with
Tribes and Tribal organizations has generally
been reliant on the personal interest of a few
State representatives. However, the system of
care movement, combined with increased
national interest in addressing racial health
disparities and the lack of culturally competent
services, has sparked more interest at the State
level for Tribal-State partnerships. States are
searching for methods that could more
effectively address high cost institutional and
residential treatment services that are utilized
when behavioral health needs are not met in the
community. Thus, some States are exploring
ways to engage more Tribal organizations as
partners in behavioral health services.
Transformation of State organizational
structures, with increased support for culturally
competent practices and a re-examination of the
use of evidence-based practices, are all
opportunities to develop new partnerships with
Tribes and Tribal organizations. Conversely,
Tribal systems of care may be able to access
previously untapped State revenue sources, and
influence current and future State policy to
better address Tribal needs. For example,
Tribal–State partnerships can not only be
beneficial to Tribal communities but can
improve the health of State budgets as the high
cost of institutionalized care is transferred to
lower cost and more effective Tribal systems of
care services.
Jurisdictional confusion and misinformation
about Tribal needs also complicate
communication and partnership building. Some
State administrators erroneously believe that
Tribal needs are being met by the Indian Health
Service (IHS), when only 55 percent of
American Indians and Alaska Natives rely on
the IHS or Tribal-operated clinics or hospitals
for care. Further, the IHS budget meets less than
60 percent of the national Tribal needs, and less
than 5 percent of the Tribal mental health
needs.12
Tribal–State partnerships are also challenged by
growing State requirements that tie evidence-based
practices (EBPs) to State behavioral
health contracts.13 Tribal systems of care are
concerned that EBPs are not normed on Tribal
populations and might not be easily transferable
or appropriate for use with Tribal populations,
yet growing numbers of State and Federal
contracts require the use of EBPs. In addition,
the cost of training for manualized EBPs is often
too costly for many Tribal communities.
However, growing interest in the fields of
cultural adaptation of EBPs and support for
practice-based evidence approaches (which
include field-driven practices and traditional
practices) has opened new opportunities for
financing discussions between Tribes and
States.
12 Gone, J. P. (2004). Mental Health Services for Native
Americans in the 21st Century United States. Professional
Psychology: Research and Practice, 35(1), 10–18.
13 For the purpose of this report, the term ‘evidence-based
practices’ is used to define interventions and approaches
shown to be effective through rigorous research. This
term is synonymous with the term ‘evidence-based
treatment.’
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A10
Infrastructure
Many Tribes have both a traditional Tribal
leadership structure and a “business council”
governing structure. The Tribal business council
structure usually involves a formal election
process. Each Tribe determines its frequency of
Tribal elections (which can occur as often as
every 2 years). Election of “business” council
members is not a historic Native tradition;
rather, the Federal Government mandated it.
Tribal elections can result in the re-setting of
Tribal priorities and funding strategies. Ensuring
that Tribal council candidates and Tribal elected
officials understand the framework and purpose
of a system of care for children and families is
critical because Tribal-elected officials are
politically powerful and play a critical role in
both short and long-term sustainability plans.
The national field of behavioral health rests on a
foundation of formal licenses, credentials, and
program accreditation—all critical components
of sustainability, especially if the sustainability
plan includes third-party billing for behavioral
health services.
Another factor that can complicate sustainability
plans is AI/AN preference in hiring practices.
Part of Tribal self-determination policy, Tribes
and Tribal organizations are legally sanctioned
to have AI/AN preference in hiring practices
through Tribal exemption to Title VII of the
Civil Rights Act (1964). AI/AN preference in
hiring is not only allowable, but often a policy
and mission for Tribal organizations that
support the Nation Building concept.14 AI/AN
preference in hiring is an important part of
Tribal self-determination, but may conflict with
14 Nation Building refers to the process of constructing or
structuring a nation using the power of the State (in this
case, the term “State” refers to the Tribe).
contract requirements for licensed and
credentialed staff.
Staffing
AI/AN mental health counselors are more likely
to provide culturally competent services to
Native children, youth and families because
they share a cultural affinity. As such, hiring
Native staff will promote sustainability by
increasing staff integration and involvement in
the program.15 However, AI/AN mental health
community programs often have great difficulty
finding credentialed service providers who are
AI/AN. For example, the IHS behavioral health
programs employ approximately two
psychiatrists and four psychologists per 100,000
people for the 1.5 million Native people
currently eligible for IHS funded services, in
contrast to general U.S. availability of 14
psychiatrists and 28 psychologists per 100,000
people.16
Providing funding to support the higher
education of Tribal community members is one
strategy used to address this challenge.
Promoting the accreditation of AI/AN mental
health service providers allows a community to
become self reliant in the provision of mental
health care and is posited to promote the
sustainability of mental health programs.
In a study involving 401 American Indian
youths and 188 American Indian providers,
15 Mancini, J. A., & Marek, L. I. (2004). Sustaining
community based programs: Examination of relationships
between sustainability factors and program results.
Family Relations, 53, 339–347.
16 West, J., Kohout, J., Pion, G. M., Wicherski, M. M.,
Vandivort-Warren, R. E., Palmiter, M. L. , et al. (2000).
Mental health practitioners and trainees. In R.W.
Manderscheid & M.J. Henderson (EDs.), Mental health,
United States, 2000. Rockville, MD: U.S. Department of
Health and Human Services
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A11
researchers found that providers were more
likely to correctly identify the problems of
American Indian youth and offer them, or refer
them for, services when the provider was
knowledgeable about mental health problems
and available resources in the community.17
These results suggest that to best assess the
needs of American Indian youth, providers need
to have both an understanding of the local
culture and community resources, and a formal
education in mental health service provision to
provide the most culturally and clinically
meaningful services. Effective treatment will in
turn promote program sustainability.
Primarily due to the shortage of Master’s- and
Ph.D.-level Tribal behavioral health specialists,
many Tribal systems of care hire non-Native
professionals to serve in clinical supervisory or
managerial positions. A frequent challenge to
newly hired non-Native clinical supervisors is
that they must recognize that the Tribal
paraprofessionals hold the expert knowledge on
Tribal community needs and cultural
engagement strategies. Training in Tribal
approaches and Tribal life ways can be a
multiyear transition for the non-Native
professional, however investment in training
and supervision of non-Native staff is critical to
prevent costly staff turnover. To address the
immediacy of the mental health needs of the
AI/AN population, many mental health
programs have developed cultural competence
training curriculums to teach non-Native
providers about the culture of the AI/AN
community in which they will be providing
17 Stiffman, A. R., Freedenthal, S., Dore, P., Ostmann, E.,
Osborne, V., & Silmere, H. (2006). The role of providers
in mental health services offered to American-Indian
Youth. Psychiatric Services, 57, 1185–1191.
services.18 Direct service supervisors can also
serve as important role models for day-to-day
sustainability practices, such as generating staff
enthusiasm about the value of Tribal data for
program planning, and ways to increase billing
accuracy.
Financing
Long-term financial sustainability requires
funding. Generally, the economic status of
Tribal communities results in meager financial
resources to draw upon and significant
competition for limited Tribal funds. Although
system of care funding and technical assistance
resources have provided training on new
approaches to the fund-development process,
some Tribal communities are able to seize these
opportunities, while the ability of others to
maximize such opportunities has been
compromised. There are many reasons why
some Tribal communities are challenged in
developing their financing capacity, which often
include a lack of a comprehensive strategic plan
to address the behavioral health needs of
children, youth and families and the lack of an
administrative and billing infrastructure. It also
requires a commitment from Tribal
administrative staff to build relationships with
funding sources in order to gain access to
budgets or grant cycles.
Even if a strategic plan, infrastructure, and
consistent leadership is in place, the Tribal
system of care can still be challenged by limited
resources. Last, some Tribal organizations have
difficulty in adopting a proactive approach
18 Nebelkopf, E., & King, J. (2004). A holistic system of
care for Native Americans in the San Francisco Bay Area.
In Nebelkopf, E. & Phillips, M., (Eds.), Healing and
mental health for Native Americans. New York: Altamira
Press.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A12
which some feel is the result of generations of
Federal paternalism, while others point to
historical trauma.
American Indian/Alaska Native
Medicaid Provisions
Medicaid is the largest payer for mental health
services in the country. Medicaid services are a
shared expense between the Federal
Government and State governments. The
Federal Government pays a percentage of the
total payments for services which varies based
on each State’s per capita income. The Federal
share, called the Federal Medical Assistance
Percentage (FMAP) ranges between 50 percent
and 85 percent of the total cost expended in the
State.
Important to AI/AN financing is a special
Congressional provision, embedded in the
Indian Health Care Improvement Act, which
established a match rate of 100 percent Federal
dollars and zero dollars from States for
Medicaid services offered through IHS, 638
Tribes, or 638 Tribal organizations. The 100
percent match rate was enacted because
Congress did not want to burden States with
what had been a Federal responsibility – the
health care of AI/AN people. In addition, the
100 percent FMAP rate is specifically tied to the
location of where the services are provided;
services must be provided through a tribally
owned / leased and operated facility that must be
on the official IHS facility list.
Tribal 638 organizations (Tribe or Tribal
organizations entering into a 638 agreement
with the Federal Government) providing
services at a location on the official IHS list are
eligible to receive payments are the 100 percent
FMAP rate, which means that
1. States do not have to pay a State match for
services offered through these Tribal
organizations because the Federal
Government will pay for 100 percent of the
service;
2. Tribal–State Medicaid partnerships can
result in behavioral health services to
Medicaid eligible and Medicaid enrolled
Tribal people;
3. dollars that a State would normally pay as its
part of the Medicaid matching fund could
instead remain in the State general fund;
4. State general fund savings can be spent on
other needs within the State instead of being
spent for Medicaid match.
This arrangement is a significant win-win
opportunity for both States and Tribes where
Tribal organizations provide increased health
services to Tribal youth and families at little or
no cost to the State. Many State decision makers
are not aware of this partnership opportunity
and may often be suspicious of what appears to
be a too-good-to-be-true situation. There are
significant barriers to enrollment of American
Indians and Alaska Natives in Medicaid and
SCHIP, which has led State and Tribal policy
experts to believe that the population is
significantly under enrolled in these programs.19
If the AI/AN community is not part of a Tribal
638 organization, a financially successful
alternative might be acquiring Federally
Qualified Health Center (FQHC) status, which
also allows for higher reimbursement rates.
19 Langwell, K., Laschober, M., Melman, E. & Crelia, S.
(2003). American Indian and Alaska Native Eligibility
and Enrollment in Medicaid, SCHIP, and Medicare
Individual Case Studies for Ten States. BearingPoint, Inc.
and Westat, Inc.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A13
FQHCs (and Rural Health Clinics) must be paid
on a cost basis under Federal law. States have
flexibility in determining the scope of
ambulatory services covered under the FQHC
model, which may include a variety of
behavioral health services that can support a
system of care grantee.
Match
All system of care communities are required to
make contributions, also referred to as cost
sharing, toward the system of care costs as
outlined in the Federal authorizing legislation
for systems of care (Title V, Part E section
565(b)(2) of the Public Health Services Act).
The match requirement requires that the
applicant entity will provide, directly or through
donations from public or private entities, non-
Federal contributions according to the below
formula:
■ For the first, second, and third fiscal years of
the cooperative agreement (grant), the
awardees must provide at least $1 for each
$3 of Federal funds.
■ For the fourth fiscal year, the awardees must
provide a least $1 for each $1 of Federal
funds.
■ For the fifth and sixth fiscal years, the
awardees must provide at least $2 for each
$1 of Federal funds.
The purpose of match is to encourage local
investment in the system of care by other child-serving
systems, and as evidence of the potential
of the initiative to sustain itself beyond the 6-
year award period. Matching resources may be
cash or in-kind, including facilities, equipment
or services, and must be derived from non-
Federal sources (e.g., State or sub-State non-
Federal revenues, foundation grants).
Indian Tribes receiving funds under the Self-
Determination and Education Assistance Act
(PL 93-638, as amended) are exempt from the
restriction of not using Federal sources as
match. Although only in-kind donations and
cash funds from non-Federal sources can be
used as matching funds by non-Tribal system of
care grantees, eligible Tribes and Tribal
organizations may also use Federal funds as
match under certain conditions.. Although
Federal dollars are generally not permissible for
use as “match” dollars, P.L. 638 enables Tribal
organization to use Federal dollars assumed by
Tribes through the 638 legislation as match
dollars as long as the identified 638 dollars are
not being used as Federal match by other
components of the Tribal organization or Tribal
government.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A14
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix B • Page B1
APPENDIX B. Purpose and Description of the Exploratory
Description Study
Background and Purpose of
Study
The Comprehensive Community Mental Health
Services for Children and Their Families
Program (referred to as the Child Mental Health
Initiative [CMHI]), funded by the Center for
Mental Health Services (CMHS) at the
Substance Abuse and Mental Health Services
Administration (SAMHSA), was initiated in
1992. The program was created to provide
grants to States, communities, territories, and
American Indian and Alaska Native (AI/AN)
Tribes to develop systems of care to serve
children and adolescents with, or at risk for,
emotional disorders and their families.20 A
system of care is a coordinated network of
community-based services and supports
organized to meet the challenges of children and
youth with serious mental health needs and their
families. Families and youth work in partnership
with public and private organizations to design
mental health services and supports that are
effective, that build on the strengths of
individuals, and that address each person’s
cultural and linguistic needs. A system of care
helps children, youth and families function
better at home, in school, in the community and
throughout life. Systems of care is an approach
to services that recognizes the importance of
family, school and community, and seeks to
promote the full potential of every child and
20 For the purpose of th

National Evaluation of the Comprehensive Community Mental
Health Services for Children and Their Families Program
Exploratory Description
of Financing and
Sustainability in American
Indian and Alaska Native
System of Care
Communities
Summary Report & Appendices
July 2009
Submitted to:
Substance Abuse and Mental Health Services Administration
Child, Adolescent and Family Branch
1 Choke Cherry Road, Room 6-1047
Rockville, MD 20857
Under Contract Number 280–05–0135
Submitted by:
Walter R. McDonald & Associates, Inc.
ICF Macro
Study Team:
Holly Echo-Hawk, M.S. Michelle DiMeo, M.A.
Nancy Weller, B.A. Carolyn Lichtenstein, Ph.D.
Katherine Lewis Brown, M.B.A. Elizabeth Oppenheim, J.D.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report & Appendices • Page i
Table of Contents
Introduction ................................................................................................................................. 1
Description of the Study ................................................................................................................. 2
Tribal Starting Place—The Cultural Framework ................................................................................ 3
Planning for Sustainability .............................................................................................................. 4
Political Entities and Sustainability ................................................................................................... 5
Developing Sustainable Services ..................................................................................................... 6
Strengthening Infrastructure ........................................................................................................... 8
Role of Data in Financial Sustainability ............................................................................................ 9
Assessing and Mobilizing Funding Sources .................................................................................... 10
Determining the Cost of Services .................................................................................................. 12
Medicaid as a Funding Source ..................................................................................................... 12
Developing and Sustaining Key State Partnerships .......................................................................... 14
Implications for Long-Term Financial Sustainability ........................................................................ 15
Recommendations for Financing and Sustainability in American Indian and Alaska Native
System of Care Communities ....................................................................................................... 16
Planning for Sustainability ....................................................................................................... 16
Interacting With Political Entities Regarding Financing ............................................................... 16
Developing Sustainable Services .............................................................................................. 17
Strengthening Infrastructure .................................................................................................... 17
Using Data in Financial Sustainability Planning ........................................................................ 18
Assessing and Mobilizing Funding Sources ............................................................................... 19
Determining the Cost of Services ............................................................................................. 19
Determining the Feasibility of Medicaid as a Funding Source .................................................... 20
Developing and Sustaining Key State Partnerships .................................................................... 20
Appendices
Appendix A. Understanding the Challenge: The Cultural Framework ...................................... A1
Appendix B. Purpose and Description of the Exploratory Description Study ............................... B1
Appendix C. Findings From Discussions With Project Directors, Fiscal Managers and Tribal
Board or Council Representatives ...................................................................... C1
Appendix D. Findings From Interviews With State Representatives ........................................... D1
Appendix E. National Evaluation Sustainability Study Findings for Tribal System of Care
Communities .................................................................................................... E1
Appendix F. Discussion Guides ............................................................................................. F1
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report & Appendices • Page ii
Index of Tables
Table 1. American Indian and Alaska Native System of Care Grant Communities ........................... 2
Table B–1. American Indian and Alaska Native System of Care Grant Communities ......................... B2
Table E–1. General Strategies for Maintaining Tribal Communities’ Systems of Care ........................ E2
Table E–2. Financing Strategies for Maintaining Tribal Communities’ Systems of Care ...................... E3
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 1
Introduction
he Comprehensive Community Mental
Health Services for Children and Their
Families Program (also referred to as the
Child Mental Health Initiative [CMHI]),
funded by the Center for Mental Health Services
(CMHS) at the Substance Abuse and Mental Health
Services Administration (SAMHSA), was initiated
in 1992 to provide grants to States, communities,
territories, and American Indian and Alaska Native
(AI/AN) communities to develop systems of care to
serve children and adolescents with, or at risk for,
emotional disorders and their families.1,2 A system
of care promotes the full potential of all children
and youth by addressing their physical, emotional,
intellectual, cultural, and social needs.3
AI/AN communities entered the system of care
movement in 1994 with the initial Federal grant
award to the Restoration of K’e: The Navajo Nation
Child Mental Health Project, located on the Navajo
Reservation in New Mexico. The experiences of
this initial Tribal venture into the world of national
system of care reform helped to open the doors for
the Tribal communities that followed. Fifteen Tribal
communities were funded between 1994 and 2006
and they represent the broad diversity of Tribal
people (see Table 1 for a list of the grant
communities and their primary States of
residence).4 Their cultures and languages are as
diverse as their geographic locations, which include
rural reservations, Urban Indian communities, and
Alaska Native villages.
Half of the Tribal system of care communities were
previous recipients of a 3-year Circles of Care
planning grant. The Circles of Care Initiative—
1 For the purpose of this report, the terms “American
Indian/Alaska Native,” “Native American,” “Indian,” and
“Tribal” are one and the same.
2 The 125 communities that have received, or were receiving
at the time of the study, funding through CMHI represent all
50 States and two U.S. territories.
3 http://systemsofcare.samhsa.gov/, retrieved March 25, 2008.
4 CMHI grants were awarded to 13 Tribal sovereign nations
and two Urban Indian organizations between 1994 and 2006.
described by community representatives as
invaluable—supports federally recognized Tribes,
State-recognized Tribes, and Urban Indian
communities with financial and technical assistance
to plan a culturally respectful mental health system
of care.
The material presented in this report is supported by
additional material included in the following report
appendices:
■ Appendix A. Understanding the Challenge: The
Cultural Framework
■ Appendix B. Purpose and Description of the
Exploratory Description Study
■ Appendix C. Findings from Discussions with
Project Directors, Fiscal Managers, and Tribal
Board or Council Representatives
■ Appendix D. Findings from Interviews with
State Representatives
■ Appendix E. National Evaluation Sustainability
Study Findings for Tribal Communities
In addition, the discussion guides used to gather the
data summarized in this report can be found in
Appendix F.
T
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 2
Description of the Study
The purpose of the exploratory study, conducted
between July 2007 and January 2008, was to
examine the unique financing opportunities and
challenges of Tribal systems of care in relation to
program sustainability. The overall goal of
collecting the information from this exploration was
to use study results to identify and improve
financing and sustainability strategies specifically
for Tribal communities. It is important to note that
the findings of the study are based on a small
number of participants (two or three staff from each
of the 15 Tribal system of care communities) and
the findings cannot be generalized to all Tribal
communities.
The National Evaluation Team facilitated telephone
discussions and conducted site visits with Tribal
system of care communities funded by CMHS
between 1994 and 2006. Telephone discussions
with the project director and fiscal manager of all
15 communities covered broad thematic areas that
included perspectives on sustainability; the
economic, social, and political environment;
infrastructure; services; and funding. The
discussions, conducted from July through October
2007, were unstructured, but were steered by a
topical guide.
In addition, site visits were conducted with five
Tribal system of care communities between
November 2007 and January 2008. On-site
discussions were held with a project director, fiscal
manager, Tribal Board or Council representative,
and State representative. These discussions explored
financing and sustainability successes and
challenges in more depth than the telephone
discussions. Discussions with State representatives
Table 1. American Indian and Alaska Native System of Care Grant Communities
System of Care Population of Focus State Funding Period
Graduated Communities
Restoration of K’e: The Navajo Nation
Child Mental Health Project Navajo Nation New Mexico 1994–1999
Sacred Child Project North Dakota Tribes North Dakota 1997–2003
Kmihqitahasultipon (“We Remember”)
Project Passamaquoddy Nation Maine 1997–2003
With Eagles’ Wings Project Northern Arapaho and Shoshone Tribes Wyoming 1998–2004
M’no Bmaadzid Endaad Program Sault Ste. Marie Tribe of Chippewa Indians
and Bay Mills Tribe of Chippewa Indians Michigan 1998–2004
People Working Together Project Yup’ik Eskimo and Athabascan Indians Alaska 1999–2005
Nagi Kicopi–Calling the Spirit Back
Project Oglala Sioux Tribe South Dakota 1999–2005
Ak-O-Nes Project Northern California Tribes California 2000–2006
Currently Funded Communities (at the time of the study)
Choctaw Nation CARES Project Choctaw Nation Oklahoma 2002–2008
“Ch’eghutsen” A System of Care Alaska Native Communities Alaska 2002–2008
Urban Trails Project Urban Indian Community California 2003–2009
The Po’Ka Project (Blackfeet Children
System of Care) Blackfeet Nation Montana 2005–2011
Tiwahe Wakan (Families as Sacred) Yankton Sioux Tribe South Dakota 2005–2011
Seven Generations System of Care Urban Indian Community California 2005–2011
Sewa Uusim Systems of Care Pascua Yaqui Tribe Arizona 2006–2012
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 3
focused on State agency support for Tribal systems
of care.
A Native researcher conducted all discussions in a
culturally competent manner; respect for AI/AN
historical concerns about data gathering and data
analysis guided the entire research process. The
notes taken for all discussions were qualitatively
analyzed by isolating emergent themes.
Tribal Starting Place—The
Cultural Framework
The core values of a system of care specify that
services should be child-centered, family-focused,
community-based, and culturally competent—all
values shared with many Tribal communities as part
of their traditional values and beliefs. Most of the
Tribal communities further capitalize on this
alignment by translating the system of care
terminology and approach into phrases and terms
that are meaningful to their Tribal cultures. Tribal
communities understand the relationship between a
cultural foundation to services and improved
outcomes for Tribal youth and families, and use the
system of care framework to strengthen the
development of healthy Tribal nations.
The cultural importance of program sustainability
cannot be ignored. Sustainability of community
mental health programs is especially important
within Tribal communities that lack financial
resources. For example, one leader of a Tribal
community-based substance abuse prevention and
intervention program stated,
We have a responsibility to our program
recipients. They’ve had so many losses in their
lives, and [if we] come in for a year or two or
three and give them hope, only to have the
program go away, we’ve just caused another
loss and further hopelessness in their lives.5
5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing
substance abuse in American Indian and Alaska Native
communities: The Healthy Nations Initiative. In Nebelkopf, E.
Although the
system of care
principles and
Tribal belief
systems may be
in alignment,
Tribal systems of
care continue to
face serious
challenges in
developing and
implementing
financing
strategies for
sustainability. Financing any system of care is a
strategic endeavor that involves determining what
funds will be used, how they will be used, and how
they will be managed.6 However, the financing of
Tribal systems of care is particularly complicated.
This is due to many reasons, including the lack of
financial resources in remote Tribal communities,
the impact of Tribal–State history on the
willingness and ability to pursue financial
partnerships, and the potential funding sources’ lack
of knowledge about the advantages of working with
Tribes.
Adding to the complexity of the challenge is the
meaning of federally recognized Tribes’ sovereign
status as it relates to financing; the role of Tribal
self determination; the history of confusing policies
guiding support for Tribal services; the financial
options of Tribes that are recognized by States, but
lack Federal recognition; and the unique financial
situation faced by Urban Indian communities. These
challenges become barriers to reform when there is
& Phillips, M., (Ed.), Healing and mental health for Native
Americans. New York: Altamira Press.
6 Stroul, B. A. (2007). Issue brief 1: Effective strategies to
finance a broad array of services and supports (RTC study 3:
Financing structures and strategies to support effective
systems of care, FMHI pub. #235-IB1). Tampa, FL:
University of South Florida, Louis de la Parte Florida Mental
Health Institute, Research and Training Center for Children’s
Mental Health.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 4
a lack of cross-cultural and cross-system problem
solving.
Planning for Sustainability
Findings
Many of the Tribal system of care community
representatives stressed that active and early
planning for sustainability was critical. Community
representatives discussed how planning for
systemwide transformation built on a foundation of
Tribal beliefs and Tribal ownership provided an
opportunity to break away from a previous cycle of
non-productive “planning” that had been
reactionary and short-term in nature. Some
community representatives felt that recognizing the
impact of colonialism and historical trauma on the
Tribal community’s efforts to plan was an essential
first step in breaking non-productive cycles. One
community representative argued that there was
little value in building large-scale services with
Federal funding if there was no effort to plan for
long-term sustainability. Additionally, a few
communities cautioned that fast program growth
resulting from an infusion of Federal funds can
diminish the quality of service provision if the
service structure is not carefully planned;
community representatives recommended
expanding services carefully and only to the extent
that supports are in place to ensure quality service
provision.
The Tribal system of care communities engaged in a
number of approaches to planning, which usually
began with their seeking input from the local
community on needs and service priorities as part of
their logic model development.7
Many Tribal
community representatives discussed the value of
gathering data about their community’s strengths
and needs to help with program planning and to
7 A logic model is a process to articulate the theory of change
underlying systems of care for children and families. It is a
tool for describing theories and beliefs about how and why
service systems are expected to produce particular results.
increase their competitive edge with other funding
opportunities.
Some of the planning approaches used by the Tribal
communities included
■ developing local definitions of health and
wellness with the input of community members
and Tribal elders;
■ having Tribal elders help design strategies to
infuse Tribal values, practices, and cultural
supports throughout their system of care;
■ analyzing all of the fund sources that affected
the Tribal youth and families in their States of
residence, and then determining which of the
fund sources they currently accessed and which
they needed to pursue;
■ determining the true cost of services using time
and cost studies;
■ incorporating visits to the State Medicaid office
to better understand the Medicaid provider and
billing requirements;
■ using a backward mapping process to identify
the community’s ultimate goal and detail the
steps necessary to reach the goal without
sacrificing cultural integrity;
■ developing ways to build evidence of
effectiveness and a cost base for traditional
practices;
■ developing methods to track the non-Federal
matching fund requirement.
Discussion
The close alignment of system of care values and
principles with many Tribal values and beliefs
empowers a Tribal system of care to include the
Tribal community in its planning efforts. System of
care grant requirements such as providing culturally
competent services that best meet the community to
be served, creating ways to ensure family-driven
and youth-guided care, consistently evaluating the
factors related to child and family progress, and
developing a social marketing plan that helps the
community understand the meaning of a system of
care are all opportunities for a more culturally and
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 5
linguistically appropriate and inclusive planning
model. Authentic community involvement in all
levels of planning not only gives family voice to the
process, but can clarify community needs and
wants, and helps to determine which elements of the
system of care should be sustained after the Federal
grant ends.
The Tribal system of care communities stressed that
adherence to the cultural strengths of Tribal values
becomes the screen through which all services and
fund-seeking decisions must pass. Within this
framework, the written sustainability plan can
clarify financing priorities, outline steps to be
accomplished toward each financing priority area,
list timelines for the completion of tasks, designate
key leadership roles and responsibilities, and detail
benchmarks to monitor progress toward long-term
sustainability of the Tribal system of care.
Political Entities and
Sustainability
Findings
The willingness of those who hold the power and
authority to make funding decisions has tremendous
influence on the financial sustainability of the
Tribal systems of care. The AI/AN systems of care
described the ways in which their sustainability
efforts were impacted by government agencies at
the Federal, State, Tribal, and county levels.
Each Tribal system of care community described
making significant investments of time to increase
the government funding sources’ knowledge about
why system of care services are needed and why
Tribal-driven services increase community access
and produce better outcomes. This work included
providing education about Tribal culture, Tribal
needs, Tribal sovereignty, and the Tribal approach
to child and family services. The Tribal systems of
care became expert in ways to generate political and
policy-level support for their systems of care
through education and relationship building.
Tribal–State relationships varied by State, often for
historical reasons, and community representatives
reported the value of developing partnerships with
key State officials and administrators. Many
community representatives participated in State and
county planning meetings to make Tribal needs
known, but pointed out that Tribal staff time was
limited and travel to State or county planning
meetings was time consuming.
Tribal system of care communities also provided
numerous examples of their efforts to monitor and
influence State health planning initiatives, such as
social marketing efforts to draw policy attention to
Tribal family needs. A further complication is that
several of the Tribal system of care service areas
encompass multiple States, resulting in a
multilayered process of developing relationships
with State administrators and the need to understand
multiple State child-serving initiatives.
Many community representatives discussed the
impact of Tribal politics on their sustainability
planning efforts. Some communities reported that
frequent elections of Tribal government officials
were disruptive to sustainability planning; the Tribal
election process can occur as frequently as every 2
years, and the system of care staff had to repeatedly
provide orientation about the transformative
meaning of “systems of care” to prospective, or
newly elected, leadership. Community
representatives also discussed the impact of
turnover in key Tribal government positions that
lead to a shift in priorities for the Tribe or Tribal
organization. Community representatives
emphasized that Tribal elections sometimes caused
rules to change overnight.
Discussion
Support from those with power and influence over
funding decisions is critical for the sustainability of
any system of care, but the Tribal systems of care
have the additional task of educating funding
sources about their culture and approach to Tribal
services. Tribal systems of care spend a significant
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 6
amount of time explaining what services and
supports work for Tribal families, developing ways
to document the benefits of their service array, and
negotiating strategic alliances that support the
sustainability of their systems of care.
In order to sustain financially, the Tribal system of
care communities must advance each of these areas.
For example, although each Tribal
community is aware of what mix of
clinical and cultural supports works
best for it, there remains a need to
better articulate how the cultural
supports may help advance the
clinical interventions, or how
clinical and/or medical
interventions may help open the
door for increased understanding of
the stabilizing role of cultural
supports. Also, Tribal
academicians, researchers, and
evaluators are interested in better
describing the benefits of a Tribal
service array, but many struggle
with how to describe the intersection of the different
world views represented by clinical and traditional
services. And, while Tribal communities are
experienced in developing tactical alliances, the
ultimate accomplishment of turning allied support
into actual contract dollars remains a challenge.
Developing Sustainable Services
Findings
The Tribal system of care communities described
their efforts to build an array of services that best
responded to the behavioral health needs of their
community. Their inherent knowledge of all things
Tribal (social and cultural lifestyles, spiritual
beliefs, values, communication styles, and
resources) offered a cultural advantage in designing
services to match the local need. In general, not
only do the program names of many Tribal systems
of care reflect the AI/AN value of honoring children
and youth, but their arrays of services reflect that
their culture is the foundation of their services.
Some of the communities addressed an ongoing
workforce shortage in Tribal behavioral health by
investing in training and credentialing programs for
staff to increase the quality of care and to provide
career advancement steps for paraprofessional staff.
In addition, several Tribal
communities were successful in
marketing their training program to
the State, which resulted in
modification of State provider
standards to enable the certified,
Tribal paraprofessionals to meet
requirements for third-party
reimbursement.
These successful partnerships
between the Tribal systems of care
and State governments resulted in
training and education programs that
met State credentialing requirements
as well as the cultural service needs
of Tribal communities. Many Tribal systems of care
encouraged partnership with the State from the
beginning of the curriculum development to ensure
that any obstacles to becoming a State licensed
provider of behavioral health services were readily
addressed and resolved.
Community representatives described successful
partnerships with Tribal community colleges and
universities to develop and provide training. One
community representative noted that while higher
education strengths lie in providing an academic
foundation to behavioral health knowledge, such a
setting may not always be as successful for teaching
the practical skills needed by staff to provide mental
health services. Given the urgent situations of many
Tribal youth, some communities felt that Tribal
system of care staff needed on-the-ground clinical
skills more than academic theory.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 7
The Tribal communities developed a range of
approaches to address the role of culture as part of
the assessment and treatment planning process,
including
■ relying on local cultural advisors to guide the
development of the services;
■ developing extensive cultural assessment
protocols based on the local definition of
wellness;
■ developing treatment goals to include both a
clinical and cultural assessment;
■ setting the pace and location of the “treatment”
according to local culture and individualized
needs;
■ developing Tribal behavioral health training that
benefited both the Tribal practitioner and non-
Native clinical supervisor;
■ incorporating traditional practices into the
“treatment” plan that were individualized
according to particular Tribal beliefs and family
requests.
Many of the Tribal communities discussed their
struggles with determining whether and how to seek
financial support for traditional practices.
Traditional practices can be defined in many
different ways and are an important cultural link to
the healing process. In general, the Tribal systems
of care expressed concern that seeking financial
support for traditional practices might result in
requirements for adhering to licensing and
accreditation standards.
Tribal community representatives suggested various
solutions, which included
■ developing a line item in their system of care
budgets for broadly defined cultural supports,
which might include traditional practices;
■ including references to traditional practices
within their system of care coordinator
certification process;
■ cross-walking the “treatment” goals of Tribal
traditional practices with their clinical outcome
counterparts.
Whether a treatment approach was referred to as a
traditional practice or not, many felt that promoting
culturally competent service provision was just as
important to the sustainability of their system of
care as securing financial resources.
In addition, several communities discussed the
impact of the large infusion of Federal system of
care grant dollars on their program design.
Although the Federal support enabled the
community to pay detailed attention to all elements
of Tribal service provision, a few communities
advised that too much program growth too quickly
could diminish the quality of service provision. That
is, the addition of staff without program
underpinnings in place (e.g., a full orientation to the
system of care framework, training on system of
care service expectations, and an understanding of
how the service array links to outcome measures)
could mean that the newly hired staff were not able
to work effectively as a team of system of care
providers. Therefore, some community
representatives recommended building slowly and
expanding services only to the extent that quality
service provision could be assured.
Discussion
Tribal systems of care are challenged by building
services that can be sustained beyond the Federal
grant. This requires that the system of care
leadership maintain a balance between cultural and
clinical knowledge, address workforce recruitment
and training needs, provide effective supervision
and oversight, and develop meaningful ways to
measure outcomes related to the full range of their
services. Training and education costs are critical
for workforce readiness, and supervision supports
could be an important element of workforce
retention. Another program cost is Tribal
administrative time, essential for building
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 8
relationships and educate funding sources on the
value of Tribal-driven services.
Strengthening Infrastructure
Findings
Each of the Tribal system of care communities was
at a different point on the continuum of
infrastructure development. Those that were part of
a Tribal primary health care organization often had
a reasonably strong infrastructure in place (e.g.,
computerized care management documentation, an
information technology department for computer
trouble shooting, a fully staffed finance and billing
office). Tribal systems of care that were not
attached to a health care system often had to build
their organizational infrastructure from the ground
up. This was complicated by their remote locations,
which hindered their ability to recruit and hire staff
to support their infrastructure development.
The communities discussed how the lack of local
and well organized culture-based services
contributed to the disproportionate numbers of
American Indians and Alaska Natives in juvenile
justice, foster care, child welfare, and behavioral
health systems. Most Tribal communities are rich in
culture, but poor in financial resources. When
funding for services is received in such high need
communities, the immediate focus is on delivering
services to the community. Strengthening the
service system infrastructure often takes a back seat
to mobilizing services to meet the community need.
One community representative suggested that Tribal
communities should take the time to build a solid
administrative and financial infrastructure, one that
is designed for growth. Another community
representative reported that hiring or contracting
with a public accountant to review the Tribal system
of care’s accounting system, billing capacity, and
fund oversight was an essential step in building
such infrastructure.
Community representatives discussed other aspects
of their organizational infrastructure that affected
their system of care, including the following:
Internet. The remote locations of many of the
Tribal systems of care have sporadic Internet
connectivity. This was mentioned as affecting
electronic billing capability and diminishing their
ability to comply with State contract performance
standards, such as those mandating a maximum
time period between when the service was provided
and when the data was input into State databases.
One community that increased its use of electronic
communication found that many members of its
Tribal Council were unfamiliar with the technology,
so that training had to be provided to improve the
Council members’ comfort and skill with computer
technology.
Office space. Office space is extremely scarce for
many Tribal communities, as is housing for newly
recruited staff. Due to a lack of available office
space, several communities reported having
uncomfortable working conditions or offices
scattered across several locations, creating a barrier
in staff unity. To address the lack of space, some
communities received office space from school
districts to provide school-based services. Other
communities built their own facilities. Building
office facilities, which also served as community
centers, was a large part of promoting program
sustainability for these systems of care.
Billing infrastructure. Tribal billing capacity is
critical for many financial sustainability plans, but
many finance staff in smaller Tribal organizations
have a narrowly defined responsibility of meeting
payroll and billing a grant funding source on a
once-a-month basis. Thus, establishing a complex,
third-party billing system can require a huge
investment of resources. Technical assistance from
State representatives was helpful for some to better
understand their billing processes and reduce future
billing errors. Others reported facing the challenges
of insufficient financial software or keeping up with
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 9
necessary software upgrades to meet the changing
requirements of payers. On the other hand, those
that were part of a large Tribal health care
organization reported being able to tap into existing
billing infrastructures, making the transition to
billing for mental health services less challenging.
Staff transformation. Some community
representatives discussed the challenge of
transitioning Tribal direct service staff from a long
history of working within a grant funding
environment, with no uniform expectation for a
specific number of direct service hours per week, to
a billable service hour model. The billable hour
model requires that each staff person work within
specific weekly service expectations that include an
established goal of a certain number of billable
service hours. Transitioning staff into billable hour
performance expectations was successful when the
Tribal organizations turned the billable hour
expectation into a visible team effort that
emphasized increased service to the community.
Discussion
Many Tribal organizations have made important
advances in strengthening their organizational
infrastructure as part of sustainability planning.
Consultation with financial oversight and grants
management advisors has been helpful and has
resulted in a list of action steps to achieve a stronger
infrastructure. Many Tribal systems of care have
gained much support and advice from peer-to-peer
learning opportunities. Establishing relationships
with State funding sources and State contracts
offices has been useful in better understanding data
requirements and billing processes. Tribal systems
of care have gained additional insight by exploring
a State or national accreditation process that
provides a list of action steps to prepare for
accreditation. Continuous awareness of integrating
cultural norms into the infrastructure development
is critical.
Developing a process for continuous quality
improvement (CQI) is another important step
toward financial sustainability. Unless a CQI
process is institutionalized within the Tribal
organization—especially in communities where the
need for services is great and the environment may
frequently be crisis driven—it can be easy to lose
sight of the sustainability plan. Institutionalizing a
CQI process requires the formal allocation of
responsibility for quality improvement to a person
or team with the power and authority to transform
and improve services and financing opportunities. It
is helpful for this person or team to have experience
in managing in a changing environment.
Role of Data in Financial
Sustainability
Findings
The Tribal system of care representatives discussed
general concerns about data collection that reflected
the historical mistrust held by many Tribes. Tribal
hesitation about data collection, ownership, and
analysis is based on the historical misuse and abuse
of Tribal data by some non-Tribal researchers.
However, many community representatives also
recognized the importance of tracking service use
information as part of financial reporting. The
system of care funding legislation requires grant
community participation in a national evaluation of
system of care implementation; some Tribal
communities have used this involvement as a
springboard to further develop their own local
evaluation efforts. Community representatives
emphasized the importance of Tribal “ownership”
of, and a voice in, the data collection and analysis
processes to ensure a cultural interpretation of the
data.
Discussion participants also reported the need to
improve Tribal data systems. Community
representatives from one community stressed the
usefulness of having information on the number of
clients served, the number of services rendered to
each client, the types of services rendered, and
client characteristics. Another community
representative stated that program evaluation cannot
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 10
occur without data and benchmarks. Tribal strategic
planning and system of care coordination is
hindered when basic service information is not
available across the child-serving systems.
Coordination between State reporting systems and
Tribal databases was also reported as a challenge.
One community discussed the double challenge of
using an outdated data tracking system
within the Tribal organization, but also
having to enter data into a complex
State database. Technical assistance
from the State regarding the State
databases proved helpful for one
community, but another community
discussed the need for increased Tribal
advocacy and input into State
decisions about technology upgrades
and electronic reporting requirements.
Tribal–State partnerships in improving
data technology were often successful.
A State discussant described efforts to
help Tribal organizations in obtaining technology
grants to upgrade computer equipment and to
increase the Internet speed for remote Tribal
locations, enabling reports and data for billing to be
transmitted quickly. In this win–win situation, the
State’s motivation was to facilitate Tribal access to
Medicaid billing and data tracking, and the Tribal
organization gained a multipurpose technology
upgrade.
While data collection was reported as being a time-consuming
requirement for the Tribal system of
care, it was also considered essential for justifying
the need for staff positions, revamping program
foci, securing additional funding sources,
negotiating changes with the State for provider
qualifications, focusing staff training on emerging
community needs, and promoting social marketing
endeavors.
Discussion
The system of care national evaluation process is
challenging to some Tribal communities. However,
the communities acknowledged advancements in
the use of data for sustainability planning, program
planning, and organizational change. The ability to
have program managers and evaluators on staff who
became trained and experienced with system and
client outcome indicators,
sustainability assessment measures,
and other aspects of data use was
recognized as valuable.
Although Tribes and Tribal
organizations hold a historical
distrust of data requirements, the
system of care evaluation effort
provides an opportunity for Tribal
communities to build knowledge and
adapt the data requirements in ways
that best support local needs. Tribal
systems of care are at different places
on the continuum of data use, but the
ability to develop data-based arguments for funding
of Tribal services is essential for long-term
sustainability planning.
Assessing and Mobilizing
Funding Sources
Findings
Tribal community representatives expressed
frustration with the scarcity of available funding
sources for their communities. The shortage of
funding for Tribal communities is partly due to
regional economies, confusion about which
government entity is responsible for Tribal services
and omission of Tribal services from funding
applications. One community representative
mentioned the practice of some States and counties
of including Tribal statistics in their overall
statement of need in State and/or county grant
applications, but to provide little funding to Tribal
service providers.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 11
There is a substantial lack of available funding in
rural and remote Tribal locations. One community
reported it had three experienced grant writers on
staff, but the community lacked any funding
opportunities to pursue, especially those that would
support the youth-guided and family-driven values
of a system of care. In another instance, upon the
Tribe’s receipt of the system of care grant funding,
the county within which the Tribe resided stopped
providing all previous funding to the Tribal
community and would not re-establish the financial
support once the CMHS grant funding ended,
despite system of care staff efforts. Communities
were also challenged in finding grants with
sufficient indirect cost funding to support program
administration needs.
To further complicate fund-seeking efforts, some of
the Tribal system of care communities encompass
service areas that are part of more than one State. In
these situations, multi-State political and economic
environments affect the systems of care, requiring
that Tribal communities become knowledgeable
about multiple States’ children’s initiatives,
Medicaid regulations, provider standards, and
credentialing requirements.
Matching Funds Requirement
The Federal system of care funding requires that the
grant community must make non-Federal
contributions toward program costs. Meeting the
Federal cost-sharing requirement (informally
referred to as the match requirement) is consistently
one of the greatest challenges for the Tribal systems
of care. Although the requirement encourages local
investment in the system of care by other child-serving
systems, Tribal communities represent some
of the most impoverished areas of the country. One
community reported that there were not enough
financial resources in the area to meet the match
requirements. Another community addressed this
issue by joining a coalition of Tribes to negotiate
with the Federal Government to have the
requirements waived for the poorest counties in the
country.
Communities stressed the importance of
understanding what can and cannot be used toward
the match requirement under the Federal cost-sharing
guidelines. Although eligible Tribes and
Tribal organizations receiving funds under the Self-
Determination and Education Assistance Act are
exempt from the restriction prohibiting the use of
Federal funds as match, they must ensure that the
funds received under this Act are not being used as
Federal match by other components of the Tribal
organization or Tribal government.8
Those community representatives who reported
having the most success with meeting the match
requirements had long-term relationships with State
or county funding sources; the State or county cash
grants were their match, or cost-sharing, dollars.
Most communities reported meeting the cost-sharing
requirements by assigning a cash value to
in-kind contributions. However, searching for and
documenting in-kind contributions was a labor-intensive
process that pulled time away from direct
services.
Discussion
The Tribal, State, and regional economic
environments that surround the Tribal system of
care have a direct impact on its ability to locate and
access funding support. The fund-seeking challenge
is greatly exacerbated because many of the Tribal
systems of care are located in the most
economically depressed regions in the country. The
shortage of available funding sources makes it even
more important for the Tribal system of care
communities to avoid “chasing” dollars as they
become available. Instead, time spent in developing
a sound strategic plan and a logic model delineating
the community’s theory of change would be well
spent.
8 Tribes receiving funds under the Self-Determination and
Education Assistance Act (PL 93-638, as amended) are
exempt from the restriction that prohibits the use of those
Federal funds as match as long as the funds are not being used
as match for other funding sources.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 12
Analysis and identification of funding sources that
meet the Tribal vision as well as the funding source
vision is a business-smart, strategic
process. This fund-seeking process
should be focused by the
community’s strategic plan for
sustainability that includes a well-thought-
out theory of how the local
community will change from
“service as usual” to a new
framework of a Tribal system of
care. Additional development of
strong financial and contract
reporting systems will not only help
build well-organized and effective
services, but will result in setting the
stage for replication of best service
and infrastructure practices.
Determining the Cost of Services
Findings
A fundamental step in sustainability planning is to
determine the true cost of service provision. One
community’s representatives reported that they
determined the actual cost of their services through
the use of time and cost studies. Using a time study
form, each administrative and direct service staff
person tracked how he/she spent each work day
over a specified period of time (e.g., 2 weeks). The
time study approach categorizes typical activities
and requires staff to record the amount of time spent
in each type of activity. Using this foundation of
information, the actual cost of various services
(including time spent completing client paperwork,
administrative costs, supervision costs,
transportation, etc.) was calculated. With this
information in hand, the Tribal system of care could
then negotiate payment rates with funding sources.
Discussion
Tribal programs that develop a budget or negotiate a
contract without a full determination of the actual
cost of their service provision are fiscally
vulnerable and always in a disadvantageous position
during contract negotiations. Determining an
accurate cost of services is especially critical for
culture-based services because this
type of service usually involves a
longer process for cultural
engagement and usually requires an
expanded amount of time to render
service. Time studies can help
determine the length of time used
for culture-engagement strategies,
and the amount of time needed for
each step of culture-based
treatment. Tribal communities can
then negotiate cost-based rates for
the full range of Tribal services
(e.g., clinical and cultural
assessments, community health aide
services, behavioral health care,
case management), which is critical.
States are interested in ways to reduce the high cost
of some State services and increase their
effectiveness. Negotiating with States for Tribal
service contracts is more effective if Tribal
organizations know the cost of their services and
can demonstrate that their approach to service
provision will not only be less costly to the State,
but will likely result in better outcomes.
Medicaid as a Funding Source
Findings
An essential part of many of the Tribal system of
care sustainability plans included exploration of a
partnership with Medicaid (the largest payer in the
country for behavioral health services). The
Medicaid structure, designed as a shared expense
between the Federal and State governments for
State plan-approved Medicaid services also includes
a special provision for Tribal partnerships.
This provision is related to the Federal share of the
Medicaid service cost, which is referred to as the
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 13
Federal Medical Assistance Percentage (FMAP).9
Several community representatives reported that
they spent significant amounts of time meeting with
State officials to explain the potential benefits of
Tribal–State partnerships and to negotiate access to
reimbursement rates through this special provision
in the Indian Health Care Improvement Act,
through federally qualified health center rates, or
through changes in provider standards that better
support Tribal-driven services.
The exploration of Medicaid access had many
starting places, depending on the organizational
structure and infrastructure capacity of the Tribal
system of care. For example, Tribal communities
that did not already have a national or State license
or accreditation status as a behavioral health
provider first pursued the steps to become licensed
or accredited—a necessary step toward being able
to bill Medicaid for eligible services. Most of these
communities realized that in addition to further
development of their behavioral health policies and
procedures, they also needed to focus attention on
developing their third-party billing capacity. Some
communities became knowledgeable about
Medicaid enrollment standards and explored ways
to co-locate Medicaid enrollment staff in Tribal
community locations.
The potential relationship between traditional
services and Medicaid reimbursement were
addressed in a variety of ways. Traditional services
could be classified as behavior management or
rehabilitation services in some State Medicaid Plans
9 The FMAP rate is based on the State per capita income, thus
varying from State to State; the State share of Medicaid
service costs range from 50 percent to 85 percent. A
Congressional provision of the Indian Health Care
Improvement Act established a match rate of 100 percent
Federal dollars and zero State dollars for Medicaid services
offered through the Indian Health Service (IHS), Public Law
93-638 Tribes, or Public Law 93-638 Tribal organizations. In
addition, the Tribal services must be provided through a
tribally owned/leased and operated facility that is on the
official IHS facility list. If all the requirements are met, this
FMAP option can result in cost savings to States and is one of
that recognized the value of selected traditional
practices as part of the service array. One Tribal
community employed a licensed counselor as a
clinical staff supervisor who provided cultural
services as part of the treatment plan. Some
communities addressed the use of traditional
approaches as part of treatment in their training and
certification curriculum.
Careful analysis of the State Medicaid
reimbursement rates and behavioral health billing
categories was important in Tribal community
service planning, as was the financial calculation of
the number of billable hours per week per staff
person. Some Tribal communities conducted a
crosswalk of the planned Tribal system of care’s
services with Medicaid behavioral health billing
categories to determine categorical alignment. Some
Tribal communities worked closely with State
Medicaid staff and other Medicaid providers to
explore and submit State Plan Amendments to
increase Tribal access to Medicaid services. If
amendments were not possible, continued
collaboration with the State Medicaid office
sometimes led to regulatory changes (e.g., easing of
duplicate paperwork) that facilitated a Tribal system
of care’s involvement as Medicaid providers of
services.
Challenge areas included unsuccessful access to the
State’s behavioral health managed care system and,
hence, unsuccessful access to Medicaid. Some
communities were not able to access Medicaid
services because they did not have licensed staff or
did not offer any billable services at their current
stage of service development. Some communities
were unaware that transportation is a service that
may be eligible for Medicaid reimbursement. This
is unfortunate because transportation is a significant
cost in Tribal services due to limited community
member vehicle ownership, the long geographic
distances to reach services, and the lack of financial
resources for fuel.
the reasons that Tribal systems of care explore Medicaid as a
resource for eligible services.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 14
Discussion
The historical funding resources for Tribal
behavioral health services, primarily Indian Health
Service and Bureau of Indian Affairs, remain too
meager to fully address the growing disparities and
behavioral health needs of local Tribal
communities. Tribal system of care communities
recognize that they must search for additional
financial support, and Medicaid is prominent in
most of the Tribal sustainability plans. Key to
pursuing Medicaid service coverage are several
factors: the ability of the Tribal organization or
Tribal government to develop a working
relationship with State Medicaid officials; the
design and efficacy of the Tribal service array; the
ability to recruit (or develop) a licensed workforce;
and the capacity of the Tribal infrastructure to
effectively support a third-party billing mechanism.
Developing and Sustaining Key
State Partnerships
Findings
The majority of the community representatives
spoke about the value of establishing a working
relationship with a key State administrator that later
became an important part of their sustainability
efforts. The Tribal communities used a variety of
approaches to build relationships with State
administrators, but common to their approaches was
conducting Tribal–State meetings to educate each
other on mutual needs and priority areas and
provide information about the connection between a
cultural foundation to service and improved
outcomes. One community’s strategy was to include
representatives from the county on its Tribal
advisory board to increase their exposure to Tribal
needs.
Some community representatives stressed the need
to start relationship-building with the State as early
as possible, as it could take years to get into the
State system and, ultimately, into the State budget.
Often, the State contact person became a
“champion” for Tribal services—that is, someone
who advocated within the State system for the value
of Tribal services.
The State contacts that were developed also
provided insight into the inner workings of State
system priorities and data systems, which proved
invaluable to several Tribal systems of care. For
example, some State contacts provided training on
how to negotiate a maze of county program
requirements and reporting forms. One State
champion provided assistance in understanding how
to reduce the error rate in Medicaid billing. Another
was helpful in advocating for changes in minimum
provider qualifications for case managers and care
coordinators.
The State champions were valued because they
understood sovereignty rights, valued the Tribal
expertise regarding providing services to Tribal
communities, and understood how Tribal services
could benefit the State. However, some community
representatives observed that the development of
positive relationships with representatives of their
States’ agencies was challenged by State personnel
lack of knowledge about Tribal sovereignty and
historical trauma, lack of trust between the Tribe
and the State, and staff turnover within partnering
agencies and representatives.
Discussion
Developing working relationships with key State
partners can be helpful for Tribal communities that
are trying to expand their funding sources. Tribes
and Tribal organizations that pay particular
attention to Tribal members disproportionately
using high-cost State services can then develop a
data-driven argument for Tribal service contracts.
That is, if the number of Tribal youth in high-cost
State services (e.g., juvenile corrections, non-Native
foster care, residential treatment) continues to be
out of proportion to the percentage of Tribal youth
in the overall State population, the Tribal
organizations can build their argument that
placement of Tribal youth in mainstream
institutions is not only ineffective, but very costly to
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 15
the State. Relationship building with State partners,
combined with demonstration of the effectiveness
of Tribal services, can result in service contracts for
Tribal systems of care.
Implications for Long-Term
Financial Sustainability
Examination of the financial sustainability efforts of
the 15 American Indian and Alaska Native (AI/AN)
system of care communities has resulted in
information that will be useful to Tribal service
planners, Tribal finance administrators, and system
of care funding sources. It is clear that Tribal
sovereignty and Tribal political structures
(including Urban Indian structures) have a
significant impact on financing.
Other factors impact sustainability. Historical
trauma can affect the ability of the Tribal
community to come together for productive
sustainability planning, as well as impact how much
Tribes want to develop a working relationship with
the State or county. Tribal infrastructures (e.g.,
computer technology, finance and billing systems,
and human resources) are critical to implementation
of sustainability plans, but are under-developed in
some Tribal communities. Determining the true cost
of Tribal and culturally based
services is challenging but possible.
Matching fund requirements (non-
Federal cost sharing) remain a
significant challenge in Tribal
system of care communities that
have limited resources.
Implications of the study’s findings
for next steps include the need for
finance-focused training and
technical assistance, broader
dissemination of best practices, and
the importance of peer-to-peer
learning opportunities on a range of
topics such as accreditation, Tribal–
State agreements, Medicaid
negotiations, third-party billing systems, and other
finance-related topics.
The AI/AN system of care communities have made
significant contributions to the field of cultural
competence through their community-engagement
strategies, cultural and clinical assessments,
culturally based treatment plans, and culturally
based services. This report summarizes the Tribal
contributions to the field of sustaining systems of
care through examples of Tribal infrastructure
development, Tribal–fund source relationship
building, and a range of approaches that lead to
financing for culturally based services.
Successful planning for long-term financial
sustainability
■ is a strategic process that starts early;
■ is facilitated by proactive leadership;
■ builds on a strong and stable infrastructure;
■ ensures that the system of care theory of change
is integrated into fund development plans;
■ builds collaborative relationships with national
and local Tribal resources.
The development of financial relationships that
meet serious Tribal community needs can benefit
from quality cross-cultural
communication; respect for Tribal
self-determination; understanding of
mutual financial needs,
opportunities, and restrictions; data-driven
and anecdotal understanding
of the urgency of Tribal community
needs; and a commitment to
decrease reliance on ineffective
service systems that are not working
for Tribal families.
Following are recommendations for
each of the financing and
sustainability subject areas
discussed in this report.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 16
Recommendations for Financing and Sustainability
in American Indian and Alaska Native
System of Care Communities
Planning for Sustainability
■ Begin planning for long-term financial
sustainability on the first day of the system of
care grant (or even before actually receiving the
grant), taking care to build planning on the
foundation of local cultural strengths.
■ Create a sustainability planning team that
includes key decision makers (e.g., Tribal
elected officials or Tribal administrators who
have the authority to make the needed changes,
Tribal program planners, and Tribal finance
staff).
■ Ensure active involvement of Tribal youth and
family members at the planning table, and
examine and resolve the cultural basis of any
resistance to their active leadership.
■ Use the system of care grant requirements
categories as a guide to developing a framework
for Tribal planning efforts.
■ Review the Tribal Constitution, Tribal Codes, or
the Tribal organizational mission statement for
compatibility with key system of care
principles; use the constitution, codes, or
mission statement as the mechanisms through
which the system of care transformation goals
can be met.
■ Determine the readiness of the local Tribal
offices and Tribal programs to understand and
willingly adhere to system of care values and
principles. If needed, develop a system of care
orientation for Tribal members that explains a
system of care in simple terms; use local
cultural concepts as examples.
■ Work with Tribal leadership to examine Tribal
financial capacities and resources for long-term
sustainability strategies.
■ Determine ways to incorporate the system of
care sustainability plan into the broader Tribal
financial planning; if barriers exist, discuss with
Tribal leadership ways to create a cohesive
system of care team across Tribal programs,
Tribal offices, and other Tribal resources.
■ Discuss how local Tribal values and beliefs fit
with a logic model concept and/or contribute to
the description of the Tribal theory of change.
■ Use a logic model-planning tool that best fits the
Tribal community to combine all needs
assessment and service design information into
a sustainability plan; update the plan annually
and make sure the plan is tied into the
timeframe of the overall Tribal planning
process.
Interacting With Political Entities
Regarding Financing
■ Determine who makes funding decisions within
the Federal, State, Tribal, and county
governments; determine how funding decisions
are made within these entities.
■ Assign a point person, or join a Tribal coalition,
to follow the development of State legislative
health policy and/or State administration
regulatory processes for proactive planning.
■ Stay alert to the annual or bi-annual Tribal,
State, and county budget-building processes and
make sure decision makers are aware of system
of care operational and non-Federal match
needs.
■ Build an educative relationship with Tribal
elected officials, key State Legislators, and other
local policymakers, taking care to stay in
contact on a regular basis throughout the year
and not just during a financial crisis.
■ Build alliances with Tribal elected officials,
Tribal service administrators, and/or Tribal
governing boards; negotiate inclusion of the
Tribal system of care as a standing agenda item
on the Tribal governing board agenda and
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 17
provide ongoing updates on the system of care
transformation and child and family
improvements.
■ Meet with candidates for Tribal elected offices
and orient them to the system of care approach
to services, the meaning of system of care
transformation, and budget needs.
■ Develop a data-driven argument for the need for
Tribal system of care funding, emphasizing
human and financial cost-savings by
redeploying funds from high-cost State services
that tend to be less effective to lower-cost Tribal
services that tend to be more effective.
■ Develop a cultural competence argument for
Tribal services, linking culturally competent
service provision with increased access to
services and improved child and family service
outcomes.
■ Develop a Tribal–State workgroup to examine
the over-representation of Tribal people in child
welfare, juvenile justice and education, and to
propose solutions for the elimination of
disparities.
■ Participate in Tribal, State, and county planning
meetings and present Tribal behavioral health
needs and cost-effective services that meet those
needs; request statutory or fund-shifting changes
to support the Tribal system of care.
■ Develop and/or participate in a Tribal–State
Medicaid workgroup and develop working
relationships with Tribal Medicaid liaisons.
Developing Sustainable Services
■ Conduct a planning retreat or process to
convene with key community stakeholders to
determine a local definition of wellness and to
describe how Tribal traditional culture and other
cultural influences impact access, services
provision, and service outcomes.
■ Design a cultural approach to services
(individualized for each family) that includes
strengths-based language; a cultural assessment
component of the clinical assessment; treatment
goal setting that includes attention to the role of
culture in wellness; treatment benchmarks that
include cultural strengths; and outcome
measures that show how attention to culture can
improve treatment outcomes.
■ Review traditional practices used in the
community for healing and stabilization
purposes and review the therapeutic aspects of
traditional practices (e.g., some traditional
practices may help resolve grief); cross-walk
these therapeutic practices with State-approved
behavioral health billing categories.
■ Meet with State representatives to discuss Tribal
services and any changes that are needed in
provider qualifications (e.g., expanding
Targeted Case Management to include a
provision for Tribal providers, modifying State
educational requirements for becoming a
licensed Tribal behavioral health provider).
■ Develop a staff-training curriculum based on
local Tribal values and local Tribal service
design to advance staff service skills and
credentials; meet with the State credentialing
board for licensed behavioral health providers to
discuss the Tribal curriculum concept to ensure
that the State licensing board will approve the
Tribal curriculum.
■ Partner with Tribal colleges and the State
credentialing program to implement a Tribal
system of care training and education program.
■ Develop a training plan for program managers,
clinical supervisors, and other program
management staff to ensure their knowledge is
current regarding managing change in complex
environments, staff supervision, staff
development, contract oversight, and financing
strategies.
Strengthening Infrastructure
■ Conduct a scan of infrastructure needs by
reviewing the list of system of care grant
requirements and any fundraising goals to
determine if the Tribal program has appropriate
• physical buildings and adequate service
locations;
• space for individual and family services that
meet privacy requirements;
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 18
• group space for community activities;
• office furnishings that reflect
professionalism and offer family comfort;
• clinical tools and equipment for service
provision;
• cultural tools and equipment for service
provision;
• adequate computer hardware for
communication, reporting, and training;
• functional computer software that meets
day-to-day communication and reporting
needs, including data tracking and
accounting needs;
• consistently available computer technology
staff for trouble shooting and repair;
• personnel policies and procedures, job
descriptions, and salary scales;
• policies and procedures for services, grants
management, and fiscal controls;
• billing manuals.
■ Consider hiring a Certified Public Accountant to
review current financial systems and to make
recommendations for improvement and further
development.
■ Develop and implement infrastructure
development plan that supports service growth
and includes actions steps and timelines; ensure
that it is framed within the broader context of a
Tribal logic model or theory of change.
■ Assess the feasibility of becoming a State-licensed
or nationally accredited organization by
reviewing the accreditation options, examining
the fit with the Tribal belief system, determining
the overall benefits and drawbacks to licensing
and/or accreditation, determining whether the
cost of pursuing accreditation is feasible, and
determining whether the Tribal system of care
has administrative staff available to lead the
accreditation team.
■ Upgrade billing and data reporting software
after determining if the purchase of new
software is cost effective when compared to the
volume of Tribal data processing needs.
■ Implement third-party billing capacity,
including the training and supervision needed to
transition from grants management to a third-party
billing system.
■ Overcome Tribal staff resistance to increased
documentation requirements by using Tribal
supervisors for professional modeling, oversight
and helping Tribal staff understand the
relationship between third-party billing, budget,
and increased services for the community.
■ Conduct computer skill development training
for Tribal Council or Tribal governing board
members for increased communication and
access to resources.
■ Conduct a site visit to another Tribal system of
care that has successfully implemented a
sustainability strategy, for a peer-to-peer
learning opportunity.
■ Work with Tribal administrators to ensure that
all internal systems (e.g., fiscal, technology,
management, human resources, training)
interlock, maintain close communication with
each other, and share a common goal of
advancing the Tribal system of care.
Using Data in Financial
Sustainability Planning
■ Discuss with Tribal leadership any concerns or
questions about data use and clarify the Tribal
stance on data collection, data analysis, and data
ownership.
■ Provide orientation on Tribal system of care
data use for Tribal elected officials, Tribal
governing board members, and Tribal
administrators; link data use examples to client
progress, program planning, fund development,
and contract negotiations; and emphasize ways
that Tribal data use can support Tribal self-determination
and data-driven decision making.
■ Discuss Tribal capacity for, and affiliated costs
of, a sustained data collection and data analysis
process and allocate resources for
implementation.
■ Develop data-driven arguments to support
inclusion of Tribal services in fund opportunity
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 19
language and regulatory changes to funding
processes (e.g., ways to increase Tribal access to
Medicaid reimbursement of services).
■ Determine the role of Tribal data in program
evaluation, sustainability planning, and contract
reporting.
■ Visit a Tribal system of care that has been
successful in using data for a peer-to-peer
learning opportunity.
■ Analyze aggregate data to demonstrate youth
and family improvements and related human
and financial savings.
■ Identify existing Tribal and non-Tribal data
sources that may be useful for the sustainability
planning process.
■ Advocate that State technology decisions related
to data transmission requirements must be
consistent with the technology capacities of
Tribal communities.
Assessing and Mobilizing
Funding Sources
■ Conduct a financial environmental scan and list
all funding sources in the State or region that
support Tribal children and youth; determine
which funding sources the Tribal system of care
is not accessing, and list the reasons why the
system of care has not been able to access these
sources.
■ As part of building a case for funding, compare
the percentage of the Tribal youth population in
the State with the percentage of Tribal youth in
State or county services (e.g., juvenile justice,
child welfare, residential treatment).
■ Develop data-driven funding arguments by
determining the monthly (or yearly) cost of
State, county, and private institutional care and
comparing these costs to the cost of Tribal
services.
■ Imbed the Tribal system of care sustainability
plan into all aspects of the Tribe or Tribal
organization’s overall fund development and
business operations.
■ Write a business plan for the system of care.
■ Follow the development of behavioral health
policy in Indian Health Service (IHS) and the
State legislature, or any State regulatory
discussion of existing behavioral health policy;
participate in State planning meetings as much
as possible to track and influence evolving State
initiatives and ensure that Tribal needs are
included in legislative language.
■ Develop an accreditation team to assess the
organization’s ability to complete required steps
toward State behavior health licensure and/or
national behavioral health accreditation.
■ Explore the financial feasibility of out-of-the-box
financing ideas such as developing a
business arm of the non-profit corporation.
■ Clarify what can and cannot be used as match
under the Federal cost-sharing guidelines, with
particular attention to understanding the
exemption for eligible Tribes and Tribal
organizations, which allows use of certain
Federal funds as match.
■ Develop annual goals for in-kind contributions
and local non-Federal cash contributions;
monitor all match goals on a monthly or
quarterly basis.
■ Create a list of potential in-kind contributions
(e.g., space donations, pro bono consultation)
and non-Federal cash resources (e.g., State
grants, private foundation grants).
■ Develop processes to document in-kind
contributions and the assignment of cash value
to contributions.
Determining the Cost of Services
■ Determine if the Tribe or Tribal organization is
currently using, or has previously used, a cost
study process; if necessary, seek advice from a
cost-study-experienced Tribal organization or an
Indian health planning board.
■ Determine a timeframe to implement a cost
study.
■ Provide an orientation of cost study expectations
for Tribal administration, governing board, and
staff.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report • Page 20
■ Determine the actual service and administrative
costs of the full range of Tribal behavioral
health and support services, including the costs
for administrative and supervisory time, staff
training, transportation, home visits, and
traditional practices (i.e., conduct a cost study).
■ Ensure that cost formulas address the costs of
delivering services in remote Tribal areas,
including time spent in cultural translation of
services; computer technology development and
computer training (especially related to cultural
application of service); rural Internet challenges;
cultural-based telemedicine consultation; and
off-site supervision due to the geographic range
of Tribal service locations.
Determining the Feasibility of
Medicaid as a Funding Source
■ Work closely with the Tribal government or
Tribal organization to determine the percentage
of the local Tribal population that is eligible for
and enrolled in Medicaid services.
■ Meet with Tribal administrators or the Tribal
governing board to discuss any community
perception that participation in the Medicaid
program would result in loss of IHS benefits;
consider a public community meeting to clarify
any confusion.
■ Consider negotiating the co-location of State
Medicaid enrollment staff at the Tribal location.
■ Review Tribal services, including traditional
practices, for compatibility with Medicaid
behavioral health billing categories.
■ Consider including access to Medicaid funding
as part of the Tribal sustainability plan and
outline the steps to becoming a State Medicaid
provider.
■ Develop a close and ongoing working
relationship with the State Medicaid office to
increase Tribal access to information about
Tribal enrollment strategies, provider standards,
eligible services, and billing process.
■ Meet with State Medicaid and Tribal health
representatives to determine if the 100% Federal
Medical Assistance Percentage (FMAP) option
is being fully utilized.
■ Meet with State Medicaid representatives to
discuss the development of a Tribal services
section in the State’s provider billing manual.
■ Join a coalition of Tribes in the State to explore
a waiver to the State Medicaid Plan to support
Tribal services and system of care partnerships.
Developing and Sustaining Key
State Partnerships
■ Invest in educating State officials and State
funding source administrators about the Tribal
system of care.
■ Recognize that there may be steep cultural
learning curves for Tribal and State
representatives about their respective service
systems.
■ Develop relationships with Tribal champions
within State government (e.g., non-Tribal State
administrators who acknowledge the value of
Tribal services) and provide them with
information on how Tribal-operated services
can result in positive service outcomes.
■ Ensure that the Tribal organization has the right
person at the right table; for example, send a
Tribal staff person with decision-making
responsibility to a Tribal–State meeting if
decision-making authority is needed.
■ Recognize the multiple influences on the
development of positive Tribal–State
relationships, including historical trauma and
key staff turnover at the State and in the Tribe.
■ Recognize that both States and Tribes are
concerned about the financial cost of ineffective
services and the resulting human cost to both the
Tribe and the State.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A1
APPENDIX A. Understanding the Challenge: The Cultural
Framework
Although the system of care principles and
Tribal belief systems are very much aligned,
Tribal systems of care continue to face
unparalleled challenges in developing and
implementing financing strategies for
sustainability. This is due to many reasons,
including the lack of knowledge by potential
funding sources, such as States, of the
advantages of working with Tribes, the impact
of Tribal–State history on the willingness and
ability to pursue financial partnerships, and the
lack of financial resources in remote Tribal
communities. Adding to the complexity of the
challenge is
■ the history of confusing and contradictory
Federal policies about support for Tribal
services;
■ the meaning of sovereign status of federally
recognized Tribes as it relates to financing;
■ the financial options of Tribes that are
recognized by States but lack Federal
recognition;
■ the role of Tribal self-determination and the
financial implications of Tribal assumption
of services that were previously provided by
Federal agencies.
All of these challenges are further deepened by
a lack of cross-cultural and cross-system
problem solving when partnership barriers arise.
The result are complicated jurisdictional and
policy conditions that exist between Tribes,
Federal, and State governments with many
implications for financial strategic planning.
Negotiation for financial partnership must often
start with the education of Federal, State, or
private funding sources about the relationship
between a cultural foundation to services and
improved outcomes; the impact of Tribal
sovereignty on financial partnerships; and the
values and decision-making processes of Tribal
governments, Urban Indian organizations, and
Tribal nonprofit organizational structures.
Mental health services for the American Indian
and Alaska Native (AI/AN) population are
widely documented as inadequate to provide for
the needs of the people. There are a number of
reasons for the shortage of services: the annual
Federal budget for the Indian Health Service
(IHS) is under-funded by an estimated 40–60
percent of the need for care; only 7 percent of
the IHS budget is allocated for mental health
services; a large percentage of AI/AN people
live in remote rural areas where behavioral
health services are not routinely available; and
Medicaid and other third party payers often
exclude Tribal providers from participation in
mental health networks, do not purchase the
types of services offered by Tribal health
providers, or Tribal providers are unable to
employ the types of clinical providers necessary
to render billable services.
These disparities combined with the economic
conditions in Indian country result in a
disproportionate representation of the AI/AN
population in social service programs, juvenile
and adult detention facilities, and treatment
facilities for mental health and substance abuse
problems. Thus, the impact on Federal- and
State-funded programs is also disproportionate
to the population. Statistics demonstrate that
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A2
mainstream efforts to address health, social and
economic issues in Indian country are
ineffective in addressing the root causes of these
problems. State government programs,
particularly in States with large Native
American populations, are recognizing these
costs and have become interested in partnering
with Tribal organizations for community based
service delivery.
Tribal Entities in the United
States
American Indian and Alaska Native people have
long demonstrated a high level of resilience and
have retained, or re-established, the traditions
and beliefs that serve as their cultural core.
Hundreds of Tribes continue to thrive and
remain culturally and politically unique in the
United States. Each Tribal group is organized
according to historical and cultural influences
(e.g., Tribe, Band, Nation, Pueblo, Village,
community, corporation). The Federal
Government holds special trust obligations
towards Tribal members to provide basic social,
medical, and educational services. The statutes
and treaties under which Tribal communities are
organized have a direct influence on their
financial sustainability options.
Recognition Status
More than 560 federally recognized Tribes exist
in the United States. Federally recognized
Tribes hold a government-to-government
relationship with the Federal Government.
Nearly one-half of the federally recognized
Tribes are in Alaska.
Tribes with Federal recognition status are legal
sovereign nations. Federally recognized Tribes
are rare and distinctive as they function as
independent nations within the nation of the
United States. Therefore, a unique legal and
political relationship exists between the Federal
Government and Indian Tribes. (Similarly, a
special legal relationship exists between the
Federal Government and Alaska Native
Corporations.) This relationship is grounded in
the U.S. Constitution, treaties, statutes, U.S.
Supreme Court decisions, and Federal laws and
regulations. The relationship between the
Federal Government and Tribes is also
grounded in political, legal, moral, and ethical
principles. It is important to note that the
relationship is not based upon race, but is a
government-to-government relationship.
The U.S. Department of Health and Human
Services (DHHS) has a formal consultation
policy with Tribes. Consultation with AI/AN
Tribes must occur to the extent practicable and
permitted by law before any action is taken that
will significantly affect the Tribes. In short, any
DHHS policy requires consultation with Tribes
before action by the Federal Government is
taken if the policy substantially and directly
affects one or more AI/AN Tribes; the
relationship between the Federal Government
and Tribes; or the distribution of power and
responsibilities between the Federal
Government and Tribes.
The legal and political power of sovereignty is
deep. As sovereign nations, Tribal governments
have the right to hold elections, determine their
own citizenship, and consult directly with the
Federal Government on policy, regulations,
legislation, and funding. Tribal governments can
also create and enforce laws to govern their
Tribal members. Tribal laws can be stricter or
more lenient than State laws, but they are not
subservient to State law. State laws cannot be
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A3
applied to a Tribe if the laws interfere with the
right of a Tribe to make its own laws protecting
the health and welfare of its citizens, or if they
would interfere with any Federal interest. Tribal
district courts and supreme courts can be
established to administer justice in criminal,
civil, and juvenile matters. Tribal tax
commissions, economic development
corporations, environmental protection
agencies, public works, and gaming
commissions are other examples of entities that
may be part of a Tribal government structure.
In addition to the federally recognized Tribes,
there are 245 Tribes whose lands and rights are
recognized solely by the State. A State-recognized
Tribe is an Indian Tribe that does not
have a recognized relationship with the Federal
Government through historic treaty,
Congressional act, or administrative process, but
is recognized as a Tribe by the government of
the State in which members reside or are
historically based. A lack of Federal recognition
limits the capacity of State recognized Tribes to
fully govern themselves, seek compensation for
previous loss of land, or be eligible for certain
Federal benefits and funds designated for
federally recognized Tribes. Many State-recognized
Tribes are seeking formal Federal
recognition.
Another important segment of the Tribal
population is the Urban Indian community.
‘Urban Indians’ is a term used to describe
American Indians and Alaska Natives, or
descendents of American Indians and Alaska
Natives, who have moved from their Tribes to
cities or urban areas, either voluntarily or
through forced Federal Government relocation
programs.1 Poverty and lack of economic
opportunities also contribute to the movement of
Tribal people from reservations to cities or
urban areas. More than 60 percent of all Tribal
people in the United States now live in cities or
urban areas and they remain part of the
congressionally mandated trust responsibility.
Regardless of Federal or State recognition, or
Urban Indian status, each Tribal community
reflects a distinct culture, belief system and,
often, Native language. Despite these
differences, common across all Tribal people is
a deeply ingrained sense of respect and honor
for their children (as illustrated by the names
selected for their systems of care). Many Tribal
systems of care program names reflect the
Tribe’s special recognition of children and
youth and the principal role that culture plays as
the foundation of their services.
American Indians and Alaska Natives live
within the complex and overlapping worlds of
Tribal, State, and Federal Governments—each
of these entities has unique laws, manners of
conducting business, and interpretation of
sovereignty. The relationships between Tribes
and the Federal Government, and Tribes and the
State in which they are located, are constantly
evolving. The role of Federal trust
responsibility, sovereign Tribal governments,
interpretation of Tribal and State laws, the
Urban Indian relationship with urban and Tribal
services, and the overall changing needs of
Tribal communities add to this changing
environment. All of these are key factors
affecting the financial relationships and
collaboration between Federal, State, County,
1 National Council of Urban Indian Health (2007). Fact
Sheet. Retrieved January 2008 from
http://www.ncuih.org/Fact%20Sheet.pdf
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A4
and other funding sources and Tribal
communities.
Impact of Federal Policies
Federal Government policies related to Tribal
affairs have fluctuated from open warfare to
later attempts to assimilate Tribal people into
mainstream society, from termination of Tribal
rights to later restoration of Tribal rights, and
from attempts to limit Tribal government to
later compliance with Tribal government self-determination.
These inconsistencies have
created a legacy of policy confusion that
continues to affect Tribal–Federal and Tribal–
State relationships and financing strategies
today.
A strength of the Tribal financing picture is the
Indian Self-Determination Act (Public Law 93-
638), which gives authority to Tribal
governments to assume the budget and
operations of programs and services that had
been previously carried out by the Federal
Government. This not only supports Tribal self-determination,
but also reflects support for
culturally competent practices and community
ownership. The Indian Self-Determination Act
provides the legal framework for federally
recognized Tribes and Tribal organizations to
assume the budget and operations of services
previously provided by the Federal Bureau of
Indian Affairs or the IHS. A Tribe or Tribal
organization that enters into a 638 agreement
with the Federal Government is referred to as a
“Tribal 638 organization” in this report.
Importance of Sustainability
Shediac-Rizkallah and Bone suggest three
reasons why program sustainability is
important.2 First, if a program ends while there
is still a need for services, rates of people with
untreated needs may regress to pre-intervention
levels. This is important when considering rural
AI/AN communities, which likely have limited
mental health agencies and may depend heavily
on the contributions of each agency.3 Second,
programs often incur significant start-up costs in
human, technical, and monetary resources, only
to have funds removed before a program has
reached its fullest potential. This is especially
relevant to Tribes that may have no health care
infrastructure at program start-up resulting in a
need to design an unfamiliar program,
implement major computer technology
upgrades, develop a third-party billing structure,
or provide additional training for staff who are
cultural experts but do not meet the higher
education requirements established by State or
national accreditation bodies. Third, program
sustainability promotes community investment
in future community programs and lack of
sustainability may lead to community confusion
toward future programs. Community support is
essential to the existence and persistence of
Tribal community mental health programs due
to the collectivistic orientation of AI/AN
communities.
2 Shediac-Rizkallah, M. C. & Bone, L. R. (1998).
Planning for the sustainability of community-based health
programs: conceptual frameworks and future directions
for research, practice, and policy. Health Education
Research, 13, 87–108.
3 Jim, N. (2004). The morning God comes dancing:
Culturally competent mental health and HIV services. In
Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental
health for Native Americans. New York: Altamira Press.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A5
Interest in the topic of system of care
sustainability has reached new peaks in the past
few years. Several studies have been developed
to examine aspects of system of care
sustainability. In their work, The Sustainability
of Systems of Care for Children’s Mental
Health, Stroul and Manteuffel discuss the
sustainability study undertaken by the National
Evaluation Team.4 The development of the
Web-based survey included an examination of
the various definitions of sustainability.
Emphasized was the acknowledgement that
adopting the system of care approach for the
long term requires a “sea change” in policy,
clinical practice, and administration of
children’s mental health systems and
maintenance of all of these elements of systems
of care in the face of budgetary challenges and
changing political environments. The University
of South Florida Research and Training Center,
in partnership with the National Technical
Assistance Center for Children’s Mental Health
at Georgetown University, the Human Service
Collaborative of Washington, DC, and Family
Support Systems, Inc., of Arizona, initiated a
study titled “Financing Strategies and Structures
to Support Effective Systems of Care.” The goal
of the study is to develop a better understanding
of the critical financing structures and strategies
that support systems of care. Seven critical
financing strategies are being examined and a
series of guides have been developed. None of
these studies is focused specifically on AI/AN
financing. Although the findings of these studies
provide a framework of sustainability issues
relevant to any system of care community, none
of the studies address in detail the cultural,
4 Stroul, B.A., Manteuffel, B.A. (2007). The
Sustainability of Systems of Care for Children’s Mental
political, and economic issues that are specific
to AI/AN communities and that have a direct
impact on their long term sustainability.
The cultural importance of program
sustainability must not be ignored.
Sustainability of community mental health
programs within Tribal communities is
especially important to empower and avoid re-victimization.
Lucidly expressing this point, one
leader of a Tribal community-based substance
abuse prevention and intervention program
stated,
We have a responsibility to our program
recipients. They’ve had so may losses in their
lives, and [if we] come in for a year or two or
three and give them hope, only to have the
program go away, we’ve just caused another
loss and further hopelessness in their lives.5
The 400 years of persecution, genocide, and
forced assimilation experienced by Native
Americans have led many to experience a
perception of great loss leading to anxiety and
depression or anger and avoidance.6 These
psychological consequences have been termed
“historical trauma.” It is hypothesized that
program sustainability can function to combat
such trauma by empowering Tribal communities
to decrease reliance on outside support and
Health: Lessons Learned. Journal of Behavioral Health
Services & Research.
5 Noe, T., Fleming, C., & Manson, S. (2004). Reducing
substance abuse in American Indian and Alaska Native
communities: The Healthy Nations Initiative. In
Nebelkopf, E. & Phillips, M., (Ed.), Healing and mental
health for Native Americans. New York: Altamira Press.
6 Whitbeck, L. B., Adams, G. W., Hoyt, D. R., & Chen,
X. (2004). Conceptualizing and measuring historical
trauma among American Indian people. American
Journal of Community Psychology, 33, 119–130.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A6
foster a sense of pride in being able to care for
their own community.
Factors Affecting Sustainability
Program sustainability at every level can be
impacted by the effectiveness of critical
sustainability factors. Mancini and Marek have
developed seven key elements critical for
program sustainability: (1) competent leadership
to develop a program’s vision and provide staff
training; (2) effective collaboration with
community members and key stakeholders; (3)
understanding of community needs and
resources; (4) program results demonstration;
(5) strategic funding; (6) staff involvement and
commitment to sustainability; and (7) program
responsiveness to a community’s changing
needs.7 While it is clear that many variables
interact to affect sustainability, underlying each
of these components is the need to understand
the culture of a population served. For example,
effective collaboration with Tribal community
members will be facilitated through a program
leader’s ability to integrate Tribal culture into
the development of a program’s vision. Further,
program response and results demonstrated
within an AI/AN community hinges on a
programs’ ability to provide culturally
competent care.8 Finally, obtaining long-term
financial support requires knowledge of the
resources both within Tribal communities and
outside of the Tribal community. Following are
brief discussions of key sustainability factors
known to affect program sustainability among
Tribal programs.
7 Mancini, J. A., & Marek, L. I. (2004). Sustaining
community based programs: Examination of relationships
between sustainability factors and program results.
Family Relations, 53, 339–347.
8 LaFromboise, T. (1988). American Indian mental health
policy. American Psychologists, 43, 388–397.
Economic and Political Environments
In 2000, the AI/AN poverty rate was 26 percent,
twice the national rate and greater than that of
any other ethnic group.9 Socioeconomic
conditions vary from Tribe-to-Tribe and in
different regions of the country. Some Tribal
system of care communities report
unemployment rates as high as 80 percent in the
local Tribal population. The Center for Disease
Control also mentions geographic isolation,
cultural barriers, and economic conditions as
barriers that contribute to poorer health
outcomes.10 Other studies have focused on
Tribal income increases associated with the
legalization and institution of casino gambling
for the effects on aspects of American Indian
well-being, including the effects on poverty
levels, medical care, and risk-taking behavior,
all of which are indirectly associated with health
status.11 The political environment of Tribes and
Tribal organizations is complicated; sovereign
nation status, and the Alaska Native Claims
Settlement Act (1971) which promised 44
million acres and $1 billion to Alaska Natives,
are examples of the unique aspects of the AI/AN
political environment.
9 Centers for Disease Control and Prevention.
(2003).Surveillance for health behaviors of American
Indians and Alaska Natives: Finding from the behavioral
risk factor surveillance system, 1997-2000. Morbidity and
Mortality Weekly Report. 52, 1. Retrieved January 20,
2008 from http://www.cdc.gov/mmwr/preview/
mmwrhtml/ss5207a1.htm
10 Rural Assistance Center (2008). Tribal health
frequently asked questions. Retrieved January 5, 2008
from http://www.raconline.org/info_guides/tribal/
tribalhealthfaq.php
11 Taylor, J. B., Kalt, J. P. (2005). Cabazon, The Indian
Gaming Regulatory Act, and the Socioeconomic
Consequences of American Indian Governmental
Gaming–A Ten-Year Review. American Indians on
Reservations: A Databook of Socioeconomic Change
between the 1990 and 2000 Censuses. Cambridge, MA:
The Harvard Project on American Indian Economic
Development.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A7
The Harvard Project on American Indian
Economic Development, at Harvard
University’s John F. Kennedy School of
Government, aims to understand and foster the
conditions under which sustained, self-determined
social and economic development
are achieved among American Indian nations.
At the heart of the Harvard Project research
program is the systematic, comparative study of
social and economic development on American
Indian reservations. Relevant for the Tribal
system of care communities are their key
research findings:
■ Sovereignty Matters. When Native nations
make their own decisions about what
development approaches to take, they
consistently out-perform external decision
makers—on matters as diverse as
governmental form, natural resource
management, economic development, health
care, and social service provision.
■ Institutions Matter. For development to take
hold, assertions of sovereignty must be
backed by capable institutions of
governance. Nations do this as they adopt
stable decision rules, establish fair and
independent mechanisms for dispute
resolution, and separate politics from day-to-day
business and program management.
■ Culture Matters. Successful economies
stand on the shoulders of legitimate,
culturally grounded institutions of self-government.
Indigenous societies are
diverse; each nation must equip itself with a
governing structure, economic system,
policies, and procedures that fit its own
contemporary culture.
■ Leadership Matters. Nation building
requires leaders who introduce new
knowledge and experiences, challenge
assumptions, and propose change. Such
leaders, whether elected, community, or
spiritual, convince people that things can be
different and inspire them to take action.
The Native Nations Institute is an outgrowth of
the Harvard Project on American Indian
Economic Development and serves as a self-determination,
development, and self-governance
resource to Indigenous nations. For
more than 15 years, the Harvard Project and the
Native Nations Institute researchers have
worked systematically to understand the
conditions under which sustained economic
development can be successful on American
Indian reservations in the United States and
among First Nations in Canada. These findings
indicate that, while a number of things
contribute to initiating and sustaining
reservation economic development, five are
particularly important:
■ Practical Sovereignty (genuine decision-making
power)
Native nations that have been willing and
able to assert self-governing power over
their affairs and resources have significantly
increased their chances of sustainable
economic development.
■ Capable Governance (effective governing
institutions and practices)
Sovereignty is not enough to produce
economic growth unless those rights and
powers are exercised effectively; the
chances of sustainable development rise as
Native nations put in place effective,
nonpoliticized, dispute-resolution
mechanisms that can shut down
opportunistic behavior by politicians, place
buffers between day-to-day business
management and political decisions or
interference and build capable
bureaucracies.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A8
■ Cultural Match (fit between governing
institutions and political culture)
Effective Trial governing institutions require
legitimacy with the people whose future is at
state, rooted in the fit between the formal
institutions of governance and the
indigenous conceptions of how authority
should be organized and exercised.
■ Strategic Orientation (decision making
that takes strategic considerations into
account)
Successful Native nations tend to approach
development not as a quick fix for poverty
but as a means of building a society that
works, considering long-term priorities and
concerns as well as assets and opportunities,
and bring strategic criteria to bear on
development decisions.
■ Leadership (individuals and groups who
recognize that fundamental change may
be necessary, and who can envision a
different future and persuade the
community to join them)
Successful Native nations have some group
or set of individuals who recognize the need
for fundamental change in a way things are
done; they have a vision of a future of
assertive, capable, effective self-determination
and self-governance, and can
bring the community along with them in
building that future.
In addition to these findings, gaining
community consensus on the approach to Tribal
system of care sustainability can be
complicated. Tribal systems of care often
operate within multiple governing structures
that must work together in sustainability
planning. The Tribal governing structure may
have frequent elections of Tribal officials that
result in leadership turnover and starts and stops
in sustainability planning. All of the variables
discussed, exacerbated by health disparities,
affect the AI/AN sustainability planning
process.
Planning
Planning and infrastructure development
assistance has been available for years to some
Tribal communities through the Federal
Infrastructure Development for Children’s
Mental Health Systems in AI/AN Communities
Initiative, more commonly known as the Circle
of Care Initiative. Available through a
competitive application process, the Circle of
Care Initiative supports AI/AN communities
with funding and technical assistance to plan,
design, and assess the feasibility of a culturally
respectful mental health system of care. The
Circle of Care Initiative provides 3-year grants
to State and federally recognized Tribes, Urban
Indian organizations, Tribal colleges and Tribal
universities. Successful applicants gain
community planning tools and resources to
design a holistic, community-based system of
care to support mental health and wellness for
their children, youth and families. Nearly half of
the Tribal system of care communities had
previously received a Circle of Care planning
grant that enabled them to conduct an in-depth
analysis of the existing infrastructure of the
local child-serving system to identify policy,
service gaps and potential resources, and to
facilitate culturally respectful strategic planning
activities. Also important to the Circle of Care
planning process is community-wide
engagement, development of Tribal logic
models, and development of a local evaluation
process.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A9
Partnerships
Tribal leader hesitancy to develop State or
Federal partnerships is often based in historic
distrust. Broken treaty agreements, conflicts
over land or water rights, and the removal of
Tribal children from their homes to be raised in
non-Indian boarding schools or non-Indian
foster care homes are just some of the reasons
for Tribal partnership hesitancy.
State motivation to pursue partnerships with
Tribes and Tribal organizations has generally
been reliant on the personal interest of a few
State representatives. However, the system of
care movement, combined with increased
national interest in addressing racial health
disparities and the lack of culturally competent
services, has sparked more interest at the State
level for Tribal-State partnerships. States are
searching for methods that could more
effectively address high cost institutional and
residential treatment services that are utilized
when behavioral health needs are not met in the
community. Thus, some States are exploring
ways to engage more Tribal organizations as
partners in behavioral health services.
Transformation of State organizational
structures, with increased support for culturally
competent practices and a re-examination of the
use of evidence-based practices, are all
opportunities to develop new partnerships with
Tribes and Tribal organizations. Conversely,
Tribal systems of care may be able to access
previously untapped State revenue sources, and
influence current and future State policy to
better address Tribal needs. For example,
Tribal–State partnerships can not only be
beneficial to Tribal communities but can
improve the health of State budgets as the high
cost of institutionalized care is transferred to
lower cost and more effective Tribal systems of
care services.
Jurisdictional confusion and misinformation
about Tribal needs also complicate
communication and partnership building. Some
State administrators erroneously believe that
Tribal needs are being met by the Indian Health
Service (IHS), when only 55 percent of
American Indians and Alaska Natives rely on
the IHS or Tribal-operated clinics or hospitals
for care. Further, the IHS budget meets less than
60 percent of the national Tribal needs, and less
than 5 percent of the Tribal mental health
needs.12
Tribal–State partnerships are also challenged by
growing State requirements that tie evidence-based
practices (EBPs) to State behavioral
health contracts.13 Tribal systems of care are
concerned that EBPs are not normed on Tribal
populations and might not be easily transferable
or appropriate for use with Tribal populations,
yet growing numbers of State and Federal
contracts require the use of EBPs. In addition,
the cost of training for manualized EBPs is often
too costly for many Tribal communities.
However, growing interest in the fields of
cultural adaptation of EBPs and support for
practice-based evidence approaches (which
include field-driven practices and traditional
practices) has opened new opportunities for
financing discussions between Tribes and
States.
12 Gone, J. P. (2004). Mental Health Services for Native
Americans in the 21st Century United States. Professional
Psychology: Research and Practice, 35(1), 10–18.
13 For the purpose of this report, the term ‘evidence-based
practices’ is used to define interventions and approaches
shown to be effective through rigorous research. This
term is synonymous with the term ‘evidence-based
treatment.’
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A10
Infrastructure
Many Tribes have both a traditional Tribal
leadership structure and a “business council”
governing structure. The Tribal business council
structure usually involves a formal election
process. Each Tribe determines its frequency of
Tribal elections (which can occur as often as
every 2 years). Election of “business” council
members is not a historic Native tradition;
rather, the Federal Government mandated it.
Tribal elections can result in the re-setting of
Tribal priorities and funding strategies. Ensuring
that Tribal council candidates and Tribal elected
officials understand the framework and purpose
of a system of care for children and families is
critical because Tribal-elected officials are
politically powerful and play a critical role in
both short and long-term sustainability plans.
The national field of behavioral health rests on a
foundation of formal licenses, credentials, and
program accreditation—all critical components
of sustainability, especially if the sustainability
plan includes third-party billing for behavioral
health services.
Another factor that can complicate sustainability
plans is AI/AN preference in hiring practices.
Part of Tribal self-determination policy, Tribes
and Tribal organizations are legally sanctioned
to have AI/AN preference in hiring practices
through Tribal exemption to Title VII of the
Civil Rights Act (1964). AI/AN preference in
hiring is not only allowable, but often a policy
and mission for Tribal organizations that
support the Nation Building concept.14 AI/AN
preference in hiring is an important part of
Tribal self-determination, but may conflict with
14 Nation Building refers to the process of constructing or
structuring a nation using the power of the State (in this
case, the term “State” refers to the Tribe).
contract requirements for licensed and
credentialed staff.
Staffing
AI/AN mental health counselors are more likely
to provide culturally competent services to
Native children, youth and families because
they share a cultural affinity. As such, hiring
Native staff will promote sustainability by
increasing staff integration and involvement in
the program.15 However, AI/AN mental health
community programs often have great difficulty
finding credentialed service providers who are
AI/AN. For example, the IHS behavioral health
programs employ approximately two
psychiatrists and four psychologists per 100,000
people for the 1.5 million Native people
currently eligible for IHS funded services, in
contrast to general U.S. availability of 14
psychiatrists and 28 psychologists per 100,000
people.16
Providing funding to support the higher
education of Tribal community members is one
strategy used to address this challenge.
Promoting the accreditation of AI/AN mental
health service providers allows a community to
become self reliant in the provision of mental
health care and is posited to promote the
sustainability of mental health programs.
In a study involving 401 American Indian
youths and 188 American Indian providers,
15 Mancini, J. A., & Marek, L. I. (2004). Sustaining
community based programs: Examination of relationships
between sustainability factors and program results.
Family Relations, 53, 339–347.
16 West, J., Kohout, J., Pion, G. M., Wicherski, M. M.,
Vandivort-Warren, R. E., Palmiter, M. L. , et al. (2000).
Mental health practitioners and trainees. In R.W.
Manderscheid & M.J. Henderson (EDs.), Mental health,
United States, 2000. Rockville, MD: U.S. Department of
Health and Human Services
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A11
researchers found that providers were more
likely to correctly identify the problems of
American Indian youth and offer them, or refer
them for, services when the provider was
knowledgeable about mental health problems
and available resources in the community.17
These results suggest that to best assess the
needs of American Indian youth, providers need
to have both an understanding of the local
culture and community resources, and a formal
education in mental health service provision to
provide the most culturally and clinically
meaningful services. Effective treatment will in
turn promote program sustainability.
Primarily due to the shortage of Master’s- and
Ph.D.-level Tribal behavioral health specialists,
many Tribal systems of care hire non-Native
professionals to serve in clinical supervisory or
managerial positions. A frequent challenge to
newly hired non-Native clinical supervisors is
that they must recognize that the Tribal
paraprofessionals hold the expert knowledge on
Tribal community needs and cultural
engagement strategies. Training in Tribal
approaches and Tribal life ways can be a
multiyear transition for the non-Native
professional, however investment in training
and supervision of non-Native staff is critical to
prevent costly staff turnover. To address the
immediacy of the mental health needs of the
AI/AN population, many mental health
programs have developed cultural competence
training curriculums to teach non-Native
providers about the culture of the AI/AN
community in which they will be providing
17 Stiffman, A. R., Freedenthal, S., Dore, P., Ostmann, E.,
Osborne, V., & Silmere, H. (2006). The role of providers
in mental health services offered to American-Indian
Youth. Psychiatric Services, 57, 1185–1191.
services.18 Direct service supervisors can also
serve as important role models for day-to-day
sustainability practices, such as generating staff
enthusiasm about the value of Tribal data for
program planning, and ways to increase billing
accuracy.
Financing
Long-term financial sustainability requires
funding. Generally, the economic status of
Tribal communities results in meager financial
resources to draw upon and significant
competition for limited Tribal funds. Although
system of care funding and technical assistance
resources have provided training on new
approaches to the fund-development process,
some Tribal communities are able to seize these
opportunities, while the ability of others to
maximize such opportunities has been
compromised. There are many reasons why
some Tribal communities are challenged in
developing their financing capacity, which often
include a lack of a comprehensive strategic plan
to address the behavioral health needs of
children, youth and families and the lack of an
administrative and billing infrastructure. It also
requires a commitment from Tribal
administrative staff to build relationships with
funding sources in order to gain access to
budgets or grant cycles.
Even if a strategic plan, infrastructure, and
consistent leadership is in place, the Tribal
system of care can still be challenged by limited
resources. Last, some Tribal organizations have
difficulty in adopting a proactive approach
18 Nebelkopf, E., & King, J. (2004). A holistic system of
care for Native Americans in the San Francisco Bay Area.
In Nebelkopf, E. & Phillips, M., (Eds.), Healing and
mental health for Native Americans. New York: Altamira
Press.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A12
which some feel is the result of generations of
Federal paternalism, while others point to
historical trauma.
American Indian/Alaska Native
Medicaid Provisions
Medicaid is the largest payer for mental health
services in the country. Medicaid services are a
shared expense between the Federal
Government and State governments. The
Federal Government pays a percentage of the
total payments for services which varies based
on each State’s per capita income. The Federal
share, called the Federal Medical Assistance
Percentage (FMAP) ranges between 50 percent
and 85 percent of the total cost expended in the
State.
Important to AI/AN financing is a special
Congressional provision, embedded in the
Indian Health Care Improvement Act, which
established a match rate of 100 percent Federal
dollars and zero dollars from States for
Medicaid services offered through IHS, 638
Tribes, or 638 Tribal organizations. The 100
percent match rate was enacted because
Congress did not want to burden States with
what had been a Federal responsibility – the
health care of AI/AN people. In addition, the
100 percent FMAP rate is specifically tied to the
location of where the services are provided;
services must be provided through a tribally
owned / leased and operated facility that must be
on the official IHS facility list.
Tribal 638 organizations (Tribe or Tribal
organizations entering into a 638 agreement
with the Federal Government) providing
services at a location on the official IHS list are
eligible to receive payments are the 100 percent
FMAP rate, which means that
1. States do not have to pay a State match for
services offered through these Tribal
organizations because the Federal
Government will pay for 100 percent of the
service;
2. Tribal–State Medicaid partnerships can
result in behavioral health services to
Medicaid eligible and Medicaid enrolled
Tribal people;
3. dollars that a State would normally pay as its
part of the Medicaid matching fund could
instead remain in the State general fund;
4. State general fund savings can be spent on
other needs within the State instead of being
spent for Medicaid match.
This arrangement is a significant win-win
opportunity for both States and Tribes where
Tribal organizations provide increased health
services to Tribal youth and families at little or
no cost to the State. Many State decision makers
are not aware of this partnership opportunity
and may often be suspicious of what appears to
be a too-good-to-be-true situation. There are
significant barriers to enrollment of American
Indians and Alaska Natives in Medicaid and
SCHIP, which has led State and Tribal policy
experts to believe that the population is
significantly under enrolled in these programs.19
If the AI/AN community is not part of a Tribal
638 organization, a financially successful
alternative might be acquiring Federally
Qualified Health Center (FQHC) status, which
also allows for higher reimbursement rates.
19 Langwell, K., Laschober, M., Melman, E. & Crelia, S.
(2003). American Indian and Alaska Native Eligibility
and Enrollment in Medicaid, SCHIP, and Medicare
Individual Case Studies for Ten States. BearingPoint, Inc.
and Westat, Inc.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A13
FQHCs (and Rural Health Clinics) must be paid
on a cost basis under Federal law. States have
flexibility in determining the scope of
ambulatory services covered under the FQHC
model, which may include a variety of
behavioral health services that can support a
system of care grantee.
Match
All system of care communities are required to
make contributions, also referred to as cost
sharing, toward the system of care costs as
outlined in the Federal authorizing legislation
for systems of care (Title V, Part E section
565(b)(2) of the Public Health Services Act).
The match requirement requires that the
applicant entity will provide, directly or through
donations from public or private entities, non-
Federal contributions according to the below
formula:
■ For the first, second, and third fiscal years of
the cooperative agreement (grant), the
awardees must provide at least $1 for each
$3 of Federal funds.
■ For the fourth fiscal year, the awardees must
provide a least $1 for each $1 of Federal
funds.
■ For the fifth and sixth fiscal years, the
awardees must provide at least $2 for each
$1 of Federal funds.
The purpose of match is to encourage local
investment in the system of care by other child-serving
systems, and as evidence of the potential
of the initiative to sustain itself beyond the 6-
year award period. Matching resources may be
cash or in-kind, including facilities, equipment
or services, and must be derived from non-
Federal sources (e.g., State or sub-State non-
Federal revenues, foundation grants).
Indian Tribes receiving funds under the Self-
Determination and Education Assistance Act
(PL 93-638, as amended) are exempt from the
restriction of not using Federal sources as
match. Although only in-kind donations and
cash funds from non-Federal sources can be
used as matching funds by non-Tribal system of
care grantees, eligible Tribes and Tribal
organizations may also use Federal funds as
match under certain conditions.. Although
Federal dollars are generally not permissible for
use as “match” dollars, P.L. 638 enables Tribal
organization to use Federal dollars assumed by
Tribes through the 638 legislation as match
dollars as long as the identified 638 dollars are
not being used as Federal match by other
components of the Tribal organization or Tribal
government.
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix A • Page A14
Exploratory Description of Financing and Sustainability in American Indian and Alaska Native System of Care Communities
Summary Report Appendix B • Page B1
APPENDIX B. Purpose and Description of the Exploratory
Description Study
Background and Purpose of
Study
The Comprehensive Community Mental Health
Services for Children and Their Families
Program (referred to as the Child Mental Health
Initiative [CMHI]), funded by the Center for
Mental Health Services (CMHS) at the
Substance Abuse and Mental Health Services
Administration (SAMHSA), was initiated in
1992. The program was created to provide
grants to States, communities, territories, and
American Indian and Alaska Native (AI/AN)
Tribes to develop systems of care to serve
children and adolescents with, or at risk for,
emotional disorders and their families.20 A
system of care is a coordinated network of
community-based services and supports
organized to meet the challenges of children and
youth with serious mental health needs and their
families. Families and youth work in partnership
with public and private organizations to design
mental health services and supports that are
effective, that build on the strengths of
individuals, and that address each person’s
cultural and linguistic needs. A system of care
helps children, youth and families function
better at home, in school, in the community and
throughout life. Systems of care is an approach
to services that recognizes the importance of
family, school and community, and seeks to
promote the full potential of every child and
20 For the purpose of th